Employee Safety Suggestion or Report of Hazard

Other:

Hazard Location / Concern:

Other:

Date and Time:

Suggestion for Improving Safety / Correction of Hazard:

Subject:

Hazard Report

Safety Suggestion

Description of Hazard:

OPTIONAL: Complete this section if you want a written response. (If you wish to remain anonymous, do not complete this section)

Call today for more information (530) 632-8460

LeighAnn@nxhelicopters.com

This form is for contractors, employees or vendors who wish to provide a safety suggestion or report a hazardous workplace condition or practice. Complete this form and return to the Operations Manager Sara Glass.

EMPLOYEE SAFETY SUGGESTION OR REPORT OF HAZARD

Notes:

1. Employees are advised that use of this form or other report of unsafe conditions or practices is protected by law. It is unlawful for the employer to take action against an employee in reprisal for exercising rights to participate in communications involving safety.

2. Risk Management and Administrative Services will investigate all reports or questions submitted and, if requested, will provide a written response to the

employee who provided the information or the workers in the affected area.