Safety Concern Reporting Form - Electrical Engineering 2026

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The document is a Safety Concern Reporting Form from the Safety Committee of the Penn State Department of Electrical Engineering. It allows individuals to report safety hazards or concerns, providing sections for reporter information, a detailed description of the issue, and recommendations for remediation. Additionally, it includes a section for internal use by the Safety Committee to track the assignment and resolution of reported concerns.
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  1. Click ‘Get Form’ to open the Safety Concern Reporting Form in the editor.
  2. Begin by filling out Part A – Safety Concern. Enter your name and contact number in the designated fields to identify yourself as the reporter.
  3. Next, provide the name of your supervisor and a detailed description of the safety concern or hazard you observed, including the date it was observed.
  4. Specify the building and exact location where the issue was noted. Use the text box provided to elaborate on the nature of the safety concern.
  5. Finally, write a recommendation for remedying the safety concern in the space provided. This will help ensure that appropriate actions can be taken.
  6. Once completed, review your entries for accuracy before submitting. You can easily email the form directly from our platform to Dave DeCapria at dwd2@psu.edu.

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Your system should encourage reporting all types of safety and health concerns (injuries, illnesses, anticipated hazards from new processes or equipment, unsafe conditions or behaviors, close calls/near misses, hazards from non-routine tasks and potential emergencies, weaknesses of your safety and health program).
Provide sufficient detail: State precisely what hazard has been detected and accurately identify its location, together with pictures. Document items and file reports as early as possible: Memories can fade quickly. The shorter the time between events and notation, the more accurate the reports will be.
What Does an Incident Report Need to Include? Type of incident (injury, near miss, property damage, or theft) Address. Date of incident. Time of incident. Name of affected individual. A narrative description of the incident, including the sequence of events and results of the incident. Injuries, if any.
6 Steps to Develop a Safety Plan Identify warning signs. Develop internal coping strategies. Identify people and social settings that provide distraction. Have a list of people you can ask for help. Make a list of professionals or agencies to contact during a crisis. How can I make my environment safe?
OSHA Online Compliant Form. Occupational Safety and Health Administration.

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Safety Concern Reporting Form

Safety Concern Reporting Form. Safety Committee. Penn State Department of Electrical Engineering. 111G Electrical Engineering West.

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A Just Culture in Safety Reporting |

(E.g. poor information in the form of inputs, lack of clarity about the expected outputs, lack of appropriate feedback, inadequate training and possible task

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