Unsafe Work Conditions Reporting Form

Form January 21, 2022

This webform is to be used by district employees to report potential hazards or unsafe conditions.

Person Reporting:

Anonymous:

Yes

Check box if you want to remain anonymous.

Department:

Phone Number:

Date of Incident/Hazard:

Date of Incident/Hazard Reported:

Location of Hazard: *

Description of Unsafe Condition or Hazard: *

Attach Picture 1 (if available):

Attach Picture 2 (if available):

Attach Picture 3 (if available):

Description of Incident (Reason for Reporting): *

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