Safety Concern Form (FPU-9.0042P)
This Safety Concern Form will be evaluated by a Safety Services representative and an investigation will be conducted.
Please complete this form and submit to safetyservices@floridapoly.edu.
Location of safety concern: (Building, Address, and Room Number):_______________________________________
Is there an immediate life threatening danger to the University Community? Yes No
Description of safety concern (unsafe act or conditions):
Select all those affected by the unsafe situation:
Contractor's Employees
Visitors
Other: ________________________
Students Employees
Additional Comments:
Please select your current status:
Staff Facul
ty
Student
Other: _________________________________
Date:
Name:
Email:
Signature:
FOR SAFETY SERVICES USE ONLY
Date Received: ____________________
Tracking Number: ________________
Follow up inspection
Recommendations for corrective action provided to _________
____________on ____________
University Official Date
Corrective action taken/ comments:
Phone Call
Verbal
Follow up with reporter:
Email
Emailed outcome of investigation to:
• Person Reporting Safety Concern:
• University Official:
Date Closed: _____________________________ Safety Services Staff: _____________________________
FACILITIES AND SAFETY SERVICES
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