Health & Safety Hazard Reporting Form

College/District Location Where Unsafe Conditions Exist:

Date Unsafe Condition Noticed:

Your Name: (Leave blank if you prefer to remain anonymous)

Your Phone Contact Information: (Leave blank if you prefer to remain anonymous)

Department: (Leave blank if you prefer to remain anonymous)

Your E-Mail Address: (Leave blank if you prefer to remain anonymous)

UNSAFE ACT DESCRIPTION or SAFETY HAZARD: (Describe sequence of events. Provide all of the facts you can remember)

Suggestion for Improving Safety:

Has This Matter Been Reported to Anyone on Campus?