Suggestion / Complaint Form

Employee Information

 Name (Optional): ________________________________

 Department: ___________________________
 Date: ________________________________

Type of Submission

Safety Suggestion Safety Complaint

Description

 Provide a detailed description of the safety issue or suggestion. Include specific

details about what you observed or what you propose to improve:

Proposed Solution

 If applicable, please suggest a solution or improvement:

 Have you reported this issue to your supervisor?

Yes No

Confidentiality

I prefer to remain anonymous.

I am willing to be contacted for further information. Phone:

For Office Use Only

 Received by: ___________________________

 Date: ________________________________
 Action Taken:
 Suggestion / Complaint Form

 Follow-up Required:

Yes No

 Follow-up Actions:

 Closed by: ___________________________

 Date: ________________________________