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Potential Hazard Report Form
The purpose of this form is to enable parents, members of the community, and visitors to notify the district of a potential hazard or safety issue they have identified. If the hazard poses an immediate safety issue or someone is injured, please do not use this form, immediately report the incident to the building's main office or building personnel.
Email address *
First and last name of person reporting concern: *
Your answer
Telephone # *
Your answer
Date hazard/safety Issue was first observed *
MM
/
DD
/
YYYY
Time hazard/safety issue was first observed
Time
:
Detailed description of hazard/safety issue (be as detailed as possible): *
Your answer
Location of hazard/safety issue (include building, room #, area, and/or as much detail as possible): *
Your answer
Suggestions of action to be taken (if any):
Your answer
Would you like district personnel to follow up with you? *
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