Report a Safety Concern or Incident

Welcome to the Office of Environmental Health & Safety's Hazard & Incident Notification System! All faculty members, staff, students and visitors at Cal Poly Pomona have an obligation to perform their work in a manner that does not endanger their health and safety, the well-being of others, or the university environment. Members of the campus community can participate in making the campus a safe place to work, study, and live by identifying health and/or safety hazards or unsafe conditions by informing those responsible for the problem area. Employee Notice: It is illegal for any California employer to take action against employees who exercise their right under the law to report perceived or actual unsafe and/or unhealthy conditions or hazards to their employer. Reprisal to employees for exercising their right for safety and healthy related activities will not be tolerated. If you are injured or develop a job-related illness as a result of your employment at Cal Poly Pomona, inform your supervisor/manager, get medical attention, and complete the incident report and workers' compensation claim form (https://www.cpp.edu/~workers-comp/index.shtml) once you've notified EH&S. Please note that this form is not to be used to report emergencies or eminent danger. Call 911 (campus landline) to report emergencies or contact CPP Police Department at (909) 869-3070 by mobile device. * Required

Provide Information About the Safety Concern or Incident

Date of Incident*

Time of Incident*

(Example: 10:30 AM)

Hazard/Incident Involvement**

Describe Your Involvement

Select

Hazard or Incident Category**

If you select other, please describe.

Select

Describe the safety concern.*

Name and Contact Information (Phone/E-mail) of Affected individual(s) or Witnesses Involved*

Were there Injuries or Exposures?*

Select or enter value

Did the Hazard or Incident Reported Occur in a Lab?*

Select

Building/Location*

Please indicate building or nearest location where the incident occurred.

Select or enter value

Room #

Were Other Departments/First Responders Dispatched?

If other departments/first responders were dispatched/contacted before completing this form, please list (i.e. University Police, Facilities Services, Emergency Management, an Academic Dept., etc.).

Select

Reporter's Contact Information

Providing your name and contact information will help us respond to this concern; however, providing this information is optional.

First Name

Last Name

Phone Number

(###-###-####)

Campus Affiliation

Select

Additional Information

Upload Documents or Photos

If you have documents related to or a photo of the issue you are reporting you can upload it here.

Drag and drop files here or

Send me a copy of my responses

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