Free Workplace Safety Complaint Form Template
Workplace Safety Complaint Form
Please fill out this form to submit your complaint.
Employee Information
Name
Employee ID
Department
Job Title
Phone number
Incident Details
Date of Incident
Location of Incident
Description of the Safety Concern/Incident
Type of Safety Issue
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Slip/Trip/Fall Hazard
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Fire Hazard
-
Chemical Exposure
-
Electrical Hazard
-
Machinery/Equipment Issue
-
Poor Ergonomics
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Personal Protective Equipment (PPE) Issues
Have you reported this issue to your supervisor?
Acknowledgement and Signature
I acknowledge that the information provided in this complaint is true to the best of my knowledge. I understand that any false reporting or retaliation against the individual filing the complaint will not be tolerated.
Date:
Complaint Form Templates @ Template.net
