Report of Health or Safety Concern


Complete and submit the form. After the submit button is pressed, the form and its contents will be displayed, and automatically emailed to the appropriate safety personel


Person Submitting:   Parent   Student
Email Address:    
       
Date:  Location of Problem: 
   
  Health   Safety
         Heating          Electrical
         Air Conditioning          Gas
         Sewage          Glass - Broken
         Air Quality          Stairs
         Vermin (Type:  )          Plumbing
         Cleaning/Trash Collection          Other safety issue
         Water Quality  
         Other health issue  
 
Brief Description of Problem:
                                 

           

 

 -------------------------------------- Office Use ---------------------------------------------------------------

Immediate Action:

Follow-up:

Final Outcome and Date:

Prevention or Recommendations: