Safety Hazard and Near Miss Reporting
Reporting of safety hazards or near misses help make our district an overall safer place to learn and work. These reports help us to identify and correct a hazard before it becomes an accident. You may report anything that you feel unsafe about or just want to inform the district on a certain safety item.
Please complete this form as a means of communicating these items and help prevent future incidents at Menasha Joint School District. Please know that reporting a concern is never wrong and no blame will ever be held. The sole purpose is to correct a concern before it becomes something that could hurt someone or thing. If you have any additional questions or safety concern, issue or near miss pictures to share please send them to
safety@mjsd.k12.wi.us
For questions or cases deemed immediately dangerous to life or health, call Facilities at 920-209-9693. In the case of an emergency, call 911 immediately.
* Required
What Building is the concern about?
*
Choose
Banta Elementary School
Butte Des Morts Elementary School
Clovis Grove Elementary School
Epic Academy
Gegan Elementary School
Jefferson Elementary School
Nathan Calder Stadium
Nicolet Elementary School
Maplewood Middle School
Menasha City Center District Office Building
Menasha High School
Other Location Describe in Comments
Area of concern
*
Your answer
Room Number (if applicable)
Your answer
Date of Safety Concern or Near Miss?
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MM
/
DD
/
YYYY
Time of Safety Concern or Near Miss?
*
Time
:
AM
PM
Affiliation with the School District?
*
Faculty
Staff
Student
Student Worker
Parent
Community Member
Prefer Not to Say
Other:
Safety Hazard, Concern or Near Miss Type
*
Unsafe Act
Unsafe Condition
Unsafe Equipment
Unsafe Practices
Unsafe Facility
Unsafe "Other" Explain in comments
Slip, Trip and and Fall Hazard
Cut and Abrasion Hazard
Eye Hazard
Chemical Hazard
Noise Hazard
Exposure - Temperature Hazard
Respiratory Hazard
Required
Comments describing the hazard concern or issue?
*
Your answer
Name (not required but helpful)
Your answer
Email (not required but helpful)
Your answer
Contact Number (not required but helpful)
Your answer
Submit
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