This form is to be used to notify the Citywide Safety Administrator of the following, within 24 hours of knowledge, of any of the following:
○ Regulatory inquiries, citations, notice of violations, final orders along with any pertinent documents
○ Fatality or serious injury or illness that triggers notification to regulatory agencies
○ Single incident or exposure where the department is aware that three or more employees have reported a health issue
○ Site visit by a local or state regulatory agency (e.g., Cal/OSHA, DPH, or SCAQMD )
○ On-site incidents that become the subject of significant public attention or media coverage
○ Incident where a building is evacuated for an unsafe condition

Please fill out this form to the best of your knowledge and submit within 24 hours of knowledge. Complete and accurate responses will enable us to provide the best possible support and assistance. All fields are required unless indicated otherwise. If this reporting is due to regulatory inquiries, citations, notice of violations, final orders received by the department, please email a copy of the documents to the Citywide Safety Administrator at per.safety@lacity.org in addition to the information requested in this form.

Note: This form is not a substitute for reporting and/or completing any other required accident/incident/near miss investigation forms and regulatory reporting within the required time frame.