Environmental Health & Safety

Detailed Feedback Form

Please include as many details as possible. 

This information will be sent immediately to the MSUM EH&S Director.

What do you want to comment on?

Report a ViolationNear Miss or Unsafe ActReport a SpillUnsafe ConditionStormwater Issue(Other) Other:

Date of Incident:  

Time(s):               

Location:        

Injuries:*                    Yes          No    *For any injuries, an injury report form needs to be turned into Human Resources.

Property Damage:     Yes          No

Please Describe:     

Enter your comments or incident description in the space provided below:

Tell us how to get in touch with you:  (This information will be used solely to contact you, all information is kept confidential.)

Name
E-mail
Tel
FAX

Please contact me as soon as possible regarding this matter.

Thank You!   EH&S will contact you as soon as possible regarding your comments.