Safe Sugg

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Safety Suggestion Form

Please use this form to provide safety suggestions or to


report suspected unsafe conditions in the work environment.

Date:_______________________

Description of potentially unsafe condition:______________________________________


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_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Causes or contributing factors:________________________________________________


_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Your suggestion for improving safety:__________________________________________


_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Has this issue been reported to a supervisor? ____ Yes ____ No

If yes, please provide the supervisor's name:_____________________________________

Employee Name (Optional):__________________________________________________

Department/Project Name (Optional):__________________________________________

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