Safety & Health Suggestion Form - The School District Of Philadelphia

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The School District of Philadelphia
SAFETY & HEALTH SUGGESTION FORM
To help the department / facility achieve a healthier and safer work environment, use this form to
submit suggestions for improving the health and safety of your work environment. The form can
be used to report unsafe acts or conditions and to suggest ideas for performing tasks safer. By
including your name, staff can seek clarifying information about your suggestion, and you will
receive a response to your suggestion.
Explanation of suggestion
What benefit will be received if the suggestion is implemented?
Is there a cost associated with the suggestion?
Estimated Cost $
Yes
No
Unsure
In your opinion, is there an immediate health or safety concern if the idea is not
implemented? Please explain.
Yes
No
Unsure
Work Phone Number or
YOUR NAME (optional)
Date
E-Mail

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