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safety report

District Safety Report

What are you reporting? Safety Hazard Injury/Illness Complaint

Date of Incident:

Your Name (optional):

Phone Number (optional):

Unit, Department, School, Division:

Location of Hazard or Injury/Illness ( Include building, floor, and room number.):

Summary of Incident:

Has any action been taken?

Do you want to be contacted?

Yes No

Anyone may submit this form without fear of reprisal. If you wish to remain anonymous, please leave your name blank.

Santa Rosa Junior College is officially accredited by the Western Association of Schools and Colleges