Hazard Identification &Safety Suggestion Form

This form may be used by any employee of the District to report hazardous conditions that exist in
their workplace and/or to make suggestions that will improve safety. Please be as specific as
possible. All submissions will be discussed at the next Health and Safety Committee meeting in
your building. It is not necessary to identify yourself, but additional information may be required
for the committee to respond effectively

"An employee who is discharged or otherwise discriminated against because the employee has
reported a safety hazard to the Safety and Health Committee, is subject to the protection afforded
under MN Statutes, Section 182.669"
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