Safety Committee

1.	Today's Date*
	mm/dd/yyyy

2.	This Suggestion/complaint applies to what department?*

3.	To what specific location?*

4.	To what specific process or operation?

5.	What is your suggestion or complaint? Please be as specific as possible.*

6.	Name of employee submitting suggestion/complaint (optional)

7.	If you would like your name kept confidential, please check here: If checked, only the safety committee chairperson will know your name. Your name will not be revealed to any other person. The safety committee chairperson will report the status of your complaint/recommendation back to you, personally and confidentially. THANK YOU FOR YOUR CONCERN FOR THE SAFETY OF YOUR FELLOW EMPLOYEES!
	--None--Yes No