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: