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Isthereacostassociatedwiththesuggestion?YES NO UNSURE
EstimatedCost:
YourName(optional) Date WorkPhone#
Inyouropinion,isthereanimmediatehealthorsafetyconcerniftheideaisnotimplemented?Pleaseexplain.UNSURENOYES
HEALTH&SAFETYSUGGESTIONFORMTohelptheagencyachieveahealthierandsaferworkenvironment,usethisformtoreportsuggestionsforimprovingthehealthandsafetyofyourworkenvironment.Theformcanbeusedtoreportunsafeacts,to
suggestideasforperformingtaskssafer,ortoreportsafetyhazards.Byincludingyourname,staffcanseekclarifyinginformationaboutyoursuggestion,andyouwillreceivearesponsetoyoursuggestion.Ifyouhaveasafetysuggestionpleasecompletethisfromandsubmitittothe
DGSSafetyCoordinator,403Northofficebuilding,Harrisburg,PA17125oremailittoGSsafetycommittee@pa.gov.Thankyouforyourtimeandeffort.
Explanationofsuggestion:
Whatbenefitwillbereceivedifthesuggestionisimplemented?
What benefit will be received if the suggestion is implementedRow1: Estimated Cost: Your Name optionalRow1: DateRow1: Work Phone Row1: Text1: Check Box2: Check Box3: Check Box4: Text5: Check Box6: Check Box7: Check Box9: Button1: