Safety/Health Concern

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This form is for employees to report safety and health concerns directly to the Joint Loss Management Committee. If using a paper form to submit your concerns, please submit forms to HR or any of the members listed.

Please provide the facility name and address of the hazard. *

Hazard Description: please provide details, specific location of hazard, and any other information that would be helpful. *

Did you report the hazard previously?

Yes

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Who did you report it to?

Did an incident occur because of this hazard?

Yes

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Was the incident reported?

Yes

N/A

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While this is optional, your contact information would be helpful if follow up is needed.

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