Safety Suggestion Form

January 14, 2022

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To help the Town achieve a healthier and safer work environment, use this form to submit suggestions for improving the health and safety of your work environment. This form can be used to report unsafe acts or conditions and to suggest ideas for performing tasks safer. Providing your name is optional. However, by providing your name, staff can seek clarifying information about your suggestion, and you will receive a response to your suggestion.

Name (optional)
First Last
Date of Submission * Required
MM slash DD slash YYYY
Location of unsafe condition * Required
Date of Observation * Required
MM slash DD slash YYYY
Is this COVID related? * Required
- Yes
- No
Description of potentially unsafe condition. * Required
Causes or contributing factors.
Your suggestion for improving safety.
Has this issue been reported to a supervisor? * Required
- Yes
- No
Name
You are not required but if you would like for us to follow-up, please leave your contact information below.
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Safety Suggestion Form