Safety & Health Concern Form
If your concern may result in the imminent injury or death to a patient, volunteer or employee, please contact a supervisor immediately and forego this form.

Note that concerns submitted anonymously cannot be followed up with the submitter.

Name, position, and supervisor contacted (if applicable):
For anonymous submittal, leave this part blank.
Your answer
Describe the nature of your safety concern. Include the person(s) or equipment involved, date and time of the incident, and describe the setting and situation.
Your answer
Provide your suggestion on how to resolve the issue.
Your answer
Write any additional comments here.
Your answer
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