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2. SAFETY HAZARD REPORT / SAFETY SUGGESTION FORM

   This form is to report potential safety or health hazards that could cause injury, illness, exposure, or damage to City employees, the public, or to City property.

   This form may also be used to submit safety suggestions to improve the City's Safety Program.

   The City of Napa encourages employees to participate in communications involving safety.

4. Submission Date
   Submission Date

   Submission Date
6. Submitted by:
8. Do you wish to be contacted?*

   1. Yes
   2. No
10. Provide the best number to reach you:
12. Department
14. Division
16. Location of unsafe condition or action:
18. What unsafe condition or action did you see? Describe the hazard in detail, including cause if known.
20. What do you think caused this unsafe condition or action?
22. Suggested corrective action:
24. Comments:
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field