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.

What Building is the concern about? *

Area of concern *

Room Number (if applicable)

Date of Safety Concern or Near Miss? *

YYYY

Time of Safety Concern or Near Miss? *

Time

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? *

Name (not required but helpful)

Email (not required but helpful)

Contact Number (not required but helpful)

Submit

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