HTML Preview Employee Safety Suggestion Form page number 1.
EMPLOYEE SAFETY SUGGESTION
This form is for use by employees who wish to provide a safety suggestion or report an unsafe
workplace condition or practice.
Description of unsafe condition or practice (location):
Causes or other contributing practices:
Employee's suggestion for improving safety:
Has this matter been reported to a supervisor? Yes
No
Employee's name: (Optional)
Employees are advised the use of this form or other reports of unsafe conditions or practices are protected by
law (LC 6401.7(a)(5). It would be illegal for the employer to take any action against an employee in reprisal
for exercising rights to participate in communications involving safety. The employer will investigate any
report or question as required by the Injury and Illness Prevention Program Standard (*CCR 3203) and
advise the employee who provided the information or the workers in the area of the employer's response.
For Administration Use Only:
Date affected employees informed of investigation results:
Date of correction or other completing action:
Abatement verified by:
Description of abatement action:
Submit by E-mail