Appendix B3 Injury and Illness Prevention Program
Reference: 8 CCR
IIPP Revised 04/09
Appendix
SAFETY CONCERN/SUGGESTION
Please use this form to report unsafe or uncorrected conditions that could endanger employees or students, or to make a
safety or health-related suggestion to the District Safety Committee.
Do not use this form in lieu of a work order to the maintenance department. Emergency conditions should always be reported
immediately to your supervisor.
Return this completed form to your supervisor or any member of the District Safety Committee. You may also report
conditions anonymously by writing, calling, faxing, or emailing the Program Coordinator at:
Terry Reece
Cuesta College
P.O. Box 8106
San Luis Obispo, California 93403-8106
Ph : 805-546-3283, Fax : 805-546-3920
treece@cuesta.edu
Site/School:
Today’s date: Date condition identified:
Your name (optional):
Work or office phone number (optional):
Has this condition been previously reported? Yes No Unknown
If So, To whom:
Nature of concern or suggestion
If a safety concern,
where exactly is the hazardous condition or concern?
Benefits Expected from change:
______________________________________________________________________________________
ACTION TAKEN (FOR COMMITTEE USE):
