Safety Suggestion/Risk Identification Form

Safety Suggestion/Risk Identification Form
Person Submitting Suggestion (optional)

First NameLast Name
Clinic (select all that apply)*

CollegePacific BeachMesaDowntownLa Jolla
Safety Suggestion/Risk Identified*
What do you think is wise/necessary to implement your suggestion?*
What kind of injuries/problems do you think this will help prevent?*
Discussed at Staff Meeting on

MonthDayYear
Date
Person(s) responsible for remedy
Date suggestion implemented

MonthDayYear
Date
Should be Empty: