Safety Suggestion Form

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Safety Suggestion
Energy Delivery
Revision Level B - 11/01/05
No.
(To be entered by Safety Department)
I suggest that (Attach sketch if required):
If adopted, this suggestion will prevent injuries because:
Submitted by:
Work Group:
Date:
Signature upon receiving:
3) Originator's Supervisor
Signature
Date
Reply to Suggestion:
Your Safety Suggestion has been favorably considered:
As suggested
As suggested, except as stated below
Corrective Action
(date)
Has been taken
Will be taken by
Your Safety Suggestion has been considered but will not be adopted, because:
Signature:
Date:

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