CSFS Safety Committee Form

Safety Committee Feedback

Use this form to voice concerns over near-misses, accidents or safety issues. You may submit this form anonymously, however including your personal information may help the Safety Committee to conduct a thorough review.

Name
First Last
Email
Phone
Today's Date*
MM slash DD slash YYYY
Date of Incident (if Applicable)
MM slash DD slash YYYY
Type of Comment for Safety Committee*
- Accident
- Safety Violation
- Near-Miss
- Recommendation
- Request
Description*
Please provide details related to your comment, including location & other specifics to provide context. If choosing to submit this form anonymously, please explain why, as it may help the Safety Committee to understand training needs or gaps in the agency’s safety culture.
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Optional: feel free to add a photo or supporting document.
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Safety Committee Feedback

Additional Information