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FORM F- San Joaquin County Safety Condition Report o c x Pv .o SAFETY t CONDITION REPORT c��iRoai+`� TO: DATE Submitted: Immediate SupenisoADepl.Head LOCATION&DESCRIPTION OF CONDITION AND/OR PROCEDURE.: (If applicable,provide your solution to the problem(if this is a report to the Department Head,please submit prior correspondence with immediate supervisor): CONDITION DISCUSSED WITH: , DI?PT.SUPV. Submitted by(Optional): Dept.: Print Name Signature Ee Contact#• All employees(except SEW represented employees) Employee shall report any health and safety concerns fast to their immediate supervisor. If not satisfied with the decision,please reference your respective Memorandum of Understanding(MOU)and follow procedural steps outlined. SEW represented employees Employees shall report any health and safety concerns first to their immediate supervisor. The supervisor shall have up to five business days,depending on the immediacy of the issue,to respond in writing to the employee. If the employee is not satisfied with the supervisor's response,they may appeal the matter in writing to the Department Head or his/her designee,within five business days.The Department head or his/her designee shall respond in writing within ten business days,depending on the immediacy of the issue. If not satisfied with the response,the employee may appeal,in writing,the issue to the County Safety Committee(submit this to County Human Resources/Risk Management or SEIU,Local 1021). Action taken by department,: (if no action taken please indicate why it is not necessary or appropriate) CONDITION CORRECTED: DEPARTMENT SUPERVISOR(HEAD DATE SIGNED _ Distribution:'COPY-DepartnMnl Head Completed form to be fornared In Department Head San Joaquin County Department of Public Works County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 31