District Safety Report | Environmental Health & Safety

What are you reporting? *

Safety Hazard

Injury/Illness

Complaint

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

No

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