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Environmental Health and Safety - Safety Concern Report

Safety Concern Report

This form is best viewed on a desktop computer.

This form is to be used to report potential safety or occupational health hazards at Western Kentucky University.
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:

Your Name:
Your E-mail:
Your Department:
Your Telephone:
Location of hazard:

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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 Last Modified 9/3/15