Employee Safety Report Forms

Please use the form below to submit an incident, near miss, safety observation, or a safety suggestion. Contact our safety administrators with any questions: Jason Hedeen or Tyler Carrigan, 651-923-4496. This form is for internal use only.

"*" indicates required fields

Report Type

Select type of report*

Incident

Near Miss

Safety Observation

Safety Suggestion

Was there an injury?*

Yes

Not sure

Report Information

Description and any action taken*

Location of occurrence*

Date of occurrence*

Attach an image or document

(i.e. jpg, gif, png, pdf)

Drop files here or

Max. file size: 10 MB.

Contact Information

You may be contacted with further questions for clarification.

Your Name*

First Last

Your work location*

Your department*

Your Job Title

Email*

Phone*

Today's Date*

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Name

This field is for validation purposes and should be left unchanged.