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       SAFETY CONCERN REFERRAL FORM

Safety in our schools is important to all of us, but it is of extreme importance to the Safety Committee. So that we can address the safety concerns of all individuals in our District, we need your help in identifying problems, concerns, etc. If you perceive a safety problem exists, please complete this form and it will be submitted to the Safety Committee. No problem is too small. When reporting problems, please also report what we call "Near Misses". Near Misses are incidents that could potentially have serious outcomes; i.e., tripping hazards, frayed electrical wires, improper use of equipment or inappropriate actions, etc.  All issues submitted to the committee will be discussed at its next meeting and a report on the disposition of the issue will be made back to the submitter if contact information is included. If the committee determines that a problem exists, recommendations will be made to resolve the problem or address the concern. The committee will follow this through to completion or resolution.


Date of Incident:
 
Building:
Concern: 
Comments or suggestion to improve the situation:
Name: (If you would like a response)
Email: (If you would like a response)
 
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