Safety PAWS Submission

Everyone is encouraged to report conditions or incidents that they believe could have resulted in an injury or property damage. Just PAWS - Pause for safety, Access the form, Write down your observation, and Submit!

Contact Information

Name

Phone

Classification

May EH&S contact you for additional information or provide an update on the status of your concern?

Yes

Background Information

Please completed the following fields with as much information as possible.

Date of Incident

mm/dd/yyyy

Setting

Location

Specific Location

Please provide the exact location of the incident, i.e., room number, etc.

Report Information

Please complete the following fields with as much information as possible.

Type of Incident

Description of Incident

Contributing factors that caused the incident?

Select all that apply

Potential Severity

Major

Moderate

Minor

Major - Results in death, permanent disability, or hospitalization up to 3 or more days; irreversible environmental damage; closure to business

Moderate - Results in partial permanent disability, injuries or illness to multiple persons, reversible environmental damage; violation of law, regulation, or safety guideline

Minor - Results in minor illness or injuries to persons; little or no environmental damage; does not violate law, regulation, or safety guideline

Personal Protective Equpment (PPE)

What PPE was being used?

Corrective Actions

What did you do or what do you believe should be done to prevent more serious consequences from occurring?