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SAFETY SUGGESTION/COMPLAINT FORM Code of Safe Practices Policy 2-3 Today’s Date: Your Name: Briefly Describe the Workplace Hazard: Hazard Location: Has the Hazard Been Reported to Supervisor? Yes No If So, To Whom Was It Reported and When? PLEASE RETURN FORM TO CITY SAFETY OFFICER SAFETY COMMITTEE/CITY SAFETY OFFICER USE: What Has Been Done to Correct the Hazard? Who Took Action to Correct the Hazard? jmy052018 The City assures you that no retaliation should result against you because you have participated in this process. If a situation occurs, please contact Human Resources immediately. ---PAGE BREAK--- SAFETY SUGGESTION/COMPLAINT RESPONSE Code of Safe Practices Policy 2-3 RESPONSE TO EMPLOYEE: Date of Hazard Report: Type of Hazard Reported: Action Taken: Hazard Corrected (see below) Not Identified as Hazard Date of Response to Employee: Copy to: (Affected Department Supervisor) jmy052018 ---PAGE BREAK--- SAFETY HAZARD CORRECTION FORM FOR USE BY SAFETY OFFICER ONLY Date: Submitted to: (Dept/Division) Responsible Person: The following item or procedure was not in compliance with established State of Montana and/or City of Billings safety regulations. Violation Description: Recommended Remedy: Required Action to be Taken: Before Use ASAP Immediately Response Required by: For further information, contact: City Safety & Risk Officer, JoLynn Yerger 657-3061 Public Works Safety Officer, Heidi Carver 247-8513