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t It M V <br />EMPLOYEE SAFETY INFORMATION/SUGGESTION FORM <br />All employees are encouraged to report unsafe conditions or <br />practices and to offer any suggestions for improving safety. <br />Please be assured that no one will take any action of any sort <br />against you for reporting unsafe conditions or practices or for <br />suggesting a way to improve safety. <br />We will immediately investigate any report of unsafe <br />conditions or practices and advise the employee who provided the <br />information or the workers affected of our response. We will give <br />prompt attention and consideration to all suggestions for <br />improvements. <br />This form is for use by any employee who wishes to provide a <br />safety suggestion or report an unsafe workplace condition or <br />practice. <br />DESCRIPTION OF UNSAFE CONDITION OR PRACTICE: <br />CAUSES) OF UNSAFE CONDITION OR PRACTICE OR OTHER CONTRIBUTING <br />FACTORS: <br />EMPLOYEE'S SUGGESTION FOR IMPROVING SAFETY: <br />Has This Matter Been Reported to the Supervisor? Yes No <br />Employee Name (Not Required) <br />Company, <br />Date <br />