Please use this form to provide safety suggestions or to report suspected unsafe conditions in the work environment
Date
Description of potentially unsafe condition:
Causes of contributing factors:
Your suggestion for improving safety:
Has this issue been reported to a supervisor? YesNoOther
...If Yes, please provide supervisor’s name:
...If Other, please provide explain:
Employee Name (Optional)
Name of project where Near Loss occurred (and Connelly job Number):
Please email any supporting photos or documents if necessary to: eamon@connellyandassociates.com