Environmental Health and Safety - Safety Concern Report

---

Safety Concern Report

This form is best viewed on a desktop computer.

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:

• Crime (please report this directly to the WKU Police or call 911 for an emergency)
• Incidents in which an INJURY or ILLNESS has resulted.
• For Employees (including Student Workers), please complete the Employee Accident/Near Miss Investigation Report
• For Visitors and Students (not Student Workers) please complete the Accident Report Form for Non-Employee
  
  
  If you see this don't fill out this input box.

  * Your Name:

  * Your Email:

  * Your Department:

  * Your Telephone:

  Please describe your concern:

  Has this hazard been reported to your supervisor?

  Yes

  No

  Have you notified Facilities Management if it is a building concern?

  Yes

  No

  What actions do you suggest to correct this hazzard?