District Safety Report

What are you reporting?

Safety Hazard

Injury/Illness

Complaint

Date of Incident

Your Name (optional)

Phone Number (optional)

Unit, Department, School, Division

Location of Hazard or Injury/Illness (include building, floor and room number)

Summary of Incident

Has any action been taken?

Do you want to be contacted?

Yes

Anyone may submit this form without fear of reprisal. If you wish to remain anonymous, please leave your name blank.

Employee Health & Safety