Workplace Safety Complaint Form Template
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Workplace Safety Complaint Form

Please fill out this form to submit your complaint.

Employee Information

Name

    Employee ID

      Department

        Job Title

          Phone number

            Email

              Incident Details

              Date of Incident

                Location of Incident

                  Description of the Safety Concern/Incident

                    Type of Safety Issue

                      • Slip/Trip/Fall Hazard

                      • Fire Hazard

                      • Chemical Exposure

                      • Electrical Hazard

                      • Machinery/Equipment Issue

                      • Poor Ergonomics

                      • 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