Safety Concern Report

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Safety Concern Report

This form is to be used to report potential safety or occupational health hazards.

Examples of issues to be reported on this form:

Potential fire hazards.
Slip, trip and fall hazards.
Improper removal and disposal of asbestos or any other hazardous waste.
Improper storage of hazardous materials, such as, flammables, toxic and corrosive substances
Failure to follow safe work practices.

Examples of issues NOT to be reported on this form:

Crime (please report this directly to the WKU Police or call 911 for an emergency)
Incidents in which an INJURY or ILLNESS has resulted.
- For Employees (including Student Workers), please complete the
  Employee Accident/Near Miss Investigation Report
- For Visitors and Students (not Student Workers) please complete the
  Accident Report Form for Non-Employees

Your Name:
Your E-mail:
Your Department:
Your Telephone:
Location of hazard:	(Please give Building Name, Room #, or describe Outside Area)

Please describe your concern:

Has this hazard been reported to your supervisor? Yes No

Have you notified your building coordinator if it is a building concern? Yes No

What actions do you suggest to correct this hazard?

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