Employee Safety Communication and Suggestion

Confidential and Anonymous Reporting - No name or employee ID is requested on this form.

This form allows any District employee - sworn or civilian, any rank or position, in any station or Division - to report a safety concern, hazard, near-miss/close call, Station issue, or to submit an improvement suggestion without providing identifying information. Reports are reviewed by the Wellness, Health and Safety Division / Safety Team and used to correct hazards and improve operations.

Report Information

Date of Report (required)

Station/Building with hazard (required)

Shift (optional)

Type of Communication (Check all that apply)

(If Other)

Urgency Level

Location of Concern (General area of the Station/Division)

Description of Safety Concern, Near-Miss

Suggested Corrective Action or Improvement

Has this been Reported Before?

(If Yes)

Chain of Command

eMaintenance

(If Yes) Report details

Additional Comments

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