Employee Suggestion and Report Form

Name (Optional)

First Last

Please describe your concern or suggestion. Please be specific.

Did you directly observe the event, unsafe condition or action personally?

Do you have any recommendations for how to resolve this issue?

Has this been reported to the Supervisor or Safety Coordinator previously?

Did an illness or injury result from this issues/hazard? Was this a close call incident? If so, please describe:

For injuries or near-miss incidents, please report it directly to your supervisor or the safety coordinator. For anonymous submissions, look for a response on the lunchroom/hallway bulletin board. Your assistance in creating a safe work environment for all employees and the community is greatly appreciated.

Gynesonics, Inc. | 600 Chesapeake Drive | Redwood City, CA 94063