EHS Safety Concern Report Form

This form is for use by personnel from the CSM community who wish to report an environmental problem, an unsafe workplace condition or practice (Part A), or to provide a safety suggestion (Part B).

 

Thank you for taking the time to report your concerns about safety and/or environmental issues.  If you would like to receive an email response, please indicate your email address below. 

 


* What is your association with the Campus?
Academic Faculty (including Adjunct)
Staff
Visitor (including volunteers and contractors)
Administrative Faculty
Graduate Student
Undergraduate Student



PART A

* Descriptions of Unsafe Condition or Practice:
Causes or other Contributing Factors:
* Has This Matter Been Reported to the Area Supervisor?
Subsequent Action (if any):



PART B

Suggestion for Improving Safety or Environmental Protection:
Additional Comments:


Thank you for taking the time to report your concerns about safety and/or environmental issues. If you would like to receive an email response, please indicate your email address below.

      OPTIONAL INFORMATION:

Email Address:
Name:
Extension:
Department:


Employees and students are protected by law when reporting unsafe conditions or practices. It would be illegal and unethical for a CSM administrator or faculty member to take any action against an employee or student in reprisal for a communication involving safety. The Colorado Whistleblower's Act protects State of Colorado employees (including graduate students receiving financial aid as teaching or research assistants). In addition, EHS is a non-academic campus department that investigates reports of health and safety problems independently. EHS is not obligated to report the source of this information to academic departments, advisors, or workplace supervisors.




* required