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This form is for use by employees who wish to provide a safety suggestion or report an unsafe work place condition or practice.  Anonymous suggestions are always welcome.

Requestor Information (Not Required)

Contact:
Department: 
Phone:
E-mail:

 

Suggestion/Problem
Type
Description:

Causes/Contributing Factors:

Employee's Suggestion for Improving Safety:

Has this Matter been Reported to the Area Supervisor?

 

Employees are advised that use of this form or other reports of unsafe conditions or practices are protected by law. It is illegal for an employer to take any action against an employee in reprisal for exercising his/her right to participate in communications involving safety hazards.

CSUSM will investigate all reports of unsafe conditions as required by the Injury and Illness Prevention Program Standard (8 CCR §3203) and advise the employee who provided the information or the workers in the affected area.

 

 
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