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Safety and Security Concern Form

Please use this form to report a safety concern or safety hazard directly to Facilities Management Division (FMD) Safety and Security Unit.  This is your opportunity to promote safety awareness.  Please call 911 immediately to report emergencies that are an immediate threat to life or health to state employees and/or public. Work-related injury or illness should be reported to the employee’s supervisor and also to the FMD Safety and Security Unit.
You can complete form below or print it here.
Completed form can be emailed to:


Name (First, Last):
Where is the location of the safety hazard or safety concern? Please be as specific and descriptive as possible.
What is the nature of the safety hazard or safety concern?
Have you reported this hazard or concern before? If so, when and to whom?
Please indicate what action was taken.
Suggestions for correcting hazard:
Questions or Comments:
Security Code