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Entery your Safety Concern and
SUBMIT
to continue.
SAFETY CONCERN REPORT
1. Please select the appropriate item:
Safety Concern
Near Miss
2. Name:
Date:
Contact Information:
3. Please describe the Safety Concern/Near Miss:
4. Describe the exact location of the Safety Concern/Near Miss:
5. Has anything been done previously to address this Safety Concern/Near Miss?
Yes
No
6. If yes, what has been done?
7. If this was a Safety Concern/Near Miss, state your recommended corrective action: