Safety Concern Form

Department of Environmental and Occupational Health and Safety hazards

Today’s Date:

Contact Information First Name: * Last Name: * Email address: * Building: * Room Number: * Department: * Supervisor: *

Concern Information Location of Concern: *

Reason for Concern: *
Did an accident occur? * Yes    No If yes, provide date and time: Date:    Time:    a.m.    p.m.
Was an accident report filed with University Police? * Yes    No
Was a departmental accident/incident report filed? * Yes    No

An asterisk (*) denotes a required field