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Western Kentucky University

Environmental Health and Safety - Safety Concern Report

Safety Concern Report

This form is to be used to report potential safety or occupational health hazards at Western Kentucky University.
Examples of issues to be reported on this form:

  • Potential fire hazards.
  • Slip, trip and fall hazards.
  • Improper removal and disposal of asbestos or any other hazardous waste.
  • Improper storage of hazardous materials, such as, flammables, toxic and corrosive substances
  • Failure to follow safe work practices.

Examples of issues NOT to be reported on this form:

Your Name:
Your E-mail:
Your Department:
Your Telephone:
Location of hazard:

Please describe your concern:
Has this hazard been reported to your supervisor? Yes No
Have you notified your building coordinator if it is a building concern? Yes No

What actions do you suggest to correct this hazard?



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 Last Modified 3/31/15