Health and Safety Watchdog Incident Report

You are entitled to a healthy workplace. Fill out and submit the form if you have complaints.

If you chose other, please specify

Campus *

Date Reporting Problem *

Month

Day

Year

Person/ Groups Reporting *

Phone(s) *

Provide the phone or phones for contacting complainants

Email *

Dates of occurence *

Provide the date or dates of the incident

Location *

The building, floor, room etc. where incident occured

Description of the Problem *

How many people were affected? *

Health Problems *

Were administrative personnel informed? *

Yes

Which administrators and when *

How were administrators informed *

e.g. phone, email, memo

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