Safety Bulletin Form
Please use this form to report safety bulletin worthy incidents. All submissions are sent to Tracy Haus, Safety Director.
Name (Optional)
First Name
Last Name
Job Site Location
*
Date of the Incident
*
/
Month
/
Day
Year
Date
Severity of the Incident
*
Red (Serious Incident)
Yellow (Attention/Warning)
Green (Good Stuff)
Type of Incident
*
Unsafe Act
Unsafe Equipment
Unsafe Condition
Unsafe Use of Equipment
Good Job
Description of the Incident
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of
Corrective Action Taken
Do You Need a Response from a Member of the Safety Team?
Yes
No
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