SAFETY SUGGESTION/ENVIRONMENTAL QUALITY REPORTING FORM – Appendix 1
Warren County is committed to providing a safe and healthy environment for our employees. Your suggestions for making this
an even safer place to work are welcomed.
First, complete the following form. You may use the reverse if necessary. Then, fill in your name, department, the date, and
signature so that you will receive proper recognition for your suggestion (optional). Thank you.
SUBMIT FORM TO YOUR SUPERVISOR. THIS FORM MAY ALSO BE ANONYMOUSLY SUBMITTED TO
WARREN COUNTY SELF-INSURANCE AT: 1340 STATE ROUTE 9, LAKE GEORGE, NY 12845
Location of Current Practice/Situation
Name:
Area:
Current Practice/Situation – If applicable
Recommendation(s) – Include projected materials, equipment, and/or supplies, retraining, etc.
Desired Results
All suggestions become the property of the County
Name (optional): Date:
Department: Ext:
Signature(optional):
Thank you for taking the time to contribute your suggestion.
Follow-up
Action
Date:
Distribute to:
1-Supervisor 4-Department Head
2-Safety Officer 5-Other ________________________
3-Safety Committee
Note: Hazards that may pose an immediate danger to an employee or visitor are to be reported
to a supervisor or department head as soon as they are discovered. Also please note this is not a
work order process; please use this form to report concerns and suggestions only.
