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Safety Concern Form

A Safety Concern is any condition, practice, or violation that causes a substantial probability of physical harm, property loss, and/or environmental impact such as:

  • Loose railing on a stairwell

  • Tripping hazards

  • Anything you feel has the potential to cause harm to people, property, or the environment.

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For emergency concerns, please follow your locations emergency contact procedure(s) to be sure that the appropriate staff is aware of the issue and can respond promptly.

Submit a Safety Concern Form
Mitigated Priority Score (Severity of the issue AS YOU LEFT IT)
Initial Priority Score (Severity of the issue AS YOU FIND IT)

Corrective Actions Taken

What has been done to minimize, reduce, or eliminate this hazard?

If the INITIAL PRIORITY SCORE is above a 3, action MUST be taken immediately to protect others from the hazard and reduce the risk below that level.

Have you notified:

Check all that apply.

Thank You!
Be Safe!

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