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HEALTH AND SAFETY CONCERN FORM
Your health and safety are a priority for us!  Please complete this form to report a health and safety concern in your school/worksite.  Your concern will be forwarded to the association for review and response.  We will work with building level administration and/or senior leaders to ensure your concern is addressed and appropriately responded to.  

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First Name
Last Name
Best Phone Number to Contact You
Best Time to Call You
Best Email to Contact You
Job Title/Position
School/Worksite
Today's Date
MM
/
DD
/
YYYY
Is your health/safety concern COVID related?
Clear selection
If COVID related,  please check yes for all items related to your health/safety concern(s).
Yes
Cloth mask use
6 feet social distancing adherence
COVID screening and temperature checks
Frequently touched area(s) cleaning
Bathroom cleaning
Soap and paper towels stocked in restrooms
Hand sanitizer availability throughout the building
Disinfectant Spray/Paper Towels/Disinfectant Wipes availability
Air ventilation concern
Safety protocol training/PD
PPE Availability (Gloves, Gowns, Face Coveings, etc.)
Process for Disposal of Soiled PPE
Staff not following CCPS Safety Protocols
Students not following CCPS Safety Protocols
Visitors not following CCPS Safety Protocols
Administration not following CCPS Safety Protocols
Air ventilation concerns
Administration not enforcing adherence to CCPS Safety Protocols
Other COVID concern(s)
Clear selection
If Other, please list your COVID related concern(s) below.
Please describe in detail your health and safety concern below.  Be as specific as possible.
Do you have a specific remedy you are seeking to resolve your health/safety concern?  
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If yes, please indicate your requested remedy below.
Did you share your health/safety concern with your principal or next in line supervisor?
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If yes, when did you report the concern to administration?
MM
/
DD
/
YYYY
Please indicate below the response and/or any action taken by administration to address your health/safety concern.
Are you satisfied with administration's response?
Clear selection
Do you need us to take further action to resolve your concern?
Clear selection
Do we have your permission to bring this concern forward to CCPS senior leaders?
Clear selection
If yes, what info can we share?
Yes
No
Your name
Your work location
Your job title/position
Clear selection
Submit
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