SAFETY CONCERN FORM - CUPE 855

SAFETY CONCERN
FORM
RESULT
¤ Resolved with Dept.
¤ Referred to JHSC
Note: If the safety concern you are reporting resulted in an injury or property damage, please advise your supervisor
immediately so that an incident report can be completed. If the concern is likely to cause injury: ENSURE THAT
PRECAUTIONS ARE TAKEN TO PREVENT AN ACCIDENT before completing this form (for example – verbal warning, set
up barriers, use warning signs, lock out or remove faulty equipment).
PART I – TO BE COMPLETED BY EMPLOYEE ( See instruction on back page)
Name of Employee Completing Form:
Position:
Department:
Location of Concern:
UNION: (If applicable)
Has the supervisor been verbally informed? ¤ Yes ¤ No
TYPE OF HAZARDOUS CONDITION: (Check off condition(s) that apply)
1 ¤ Personal protective equipment issue 5 ¤ Maintenance issue
2 ¤ Unsafe equipment or material 6 ¤ Environmental: illumination, ventilation etc.
3 ¤ Fire, explosion, atmospheric hazard 7 ¤ Hazardous method or procedure
4 ¤ Unsafe design or arrangement 8 ¤ Other, please specify:
EXPLANATION & RECOMMENDATIONS: (Attach additional sheet if required)
Signature:
Date:
PART II - TO BE COMPLETED BY SUPERVISOR
Note: Supervisors shall respond to employee in writing within ten (10) working days.
SUPERVISOR’S RESPONSE:
Signature:
Date:
PART III – JOINT HEALTH & SAFETY COMMITTEE (JHSC)
Note: If the employee and/or supervisor feel that a hazardous condition still exists then the employee/supervisor should
forward this form to their health & safety representative. That representative shall bring the issue to the next Joint Health &
Safety committee meeting. The issue shall be discussed and further recommendations made.
Name of Representative Receiving Copy:
Date:
Date of Next Joint Health & Safety Committee Meeting:
Revision Date: April 15, 2009 12:59pm

INSTRUCTIONS
The purpose of this form is to provide employees with an effective means to document and
communicate health and safety concerns that exist in the workplace. The City of Kawartha Lakes
supports the identification and resolution of unsafe working conditions as quickly as is practically
possible.
Steps to Resolving a Health & Safety Concern:
STEP 1
i) Inform your immediate supervisor verbally of the health and safety issue and provide any
recommendations possible.
ii) If the hazardous condition is resolved, no further action is required.
STEP 2
i) If the safety concern has not been reasonably resolved, or it is not practical to provide the
concern verbally, complete this Safety Concern Form.
ii) Employee must complete PART I of the form. Provide as much information as necessary
to ensure the supervisor understands the exact safety concern. Provide recommendations.
iii) The employee may consult with their health & safety representative for direction in this
process.
iv) Provide factual information relevant to the concern only.
v) Forward a copy of the form to the immediate supervisor and keep a personal copy.
STEP 3
i) The immediate supervisor will review the concern and determine what action is required.
Employees are expected to follow all procedures/measures implemented to rectify the
concern.
ii) The supervisor shall respond to the employee’s concern within 10 working days of
receiving the form by completing PART II of the form.
• Forward a copy to the Director of Human Resources
• Forward a copy to the CKL H&S Co-ordinator
• Forward a copy to the employee
• Forward a copy to the UNION H&S Co-chair.
iii) Retain a copy for the department.
Step 4
i) If the employee or supervisor feel that a condition still exists, then the employee or
supervisor should contact their Health & Safety Representative. That representative shall
bring the issue to the next Joint Health & Safety Committee meeting. The issue shall be
discussed and further recommendations made.
Personal information is collected under the authority of the Occupational Health & Safety Act, s 28(1)9c) for the
purpose of identifying to management potential hazards to health & safety in the work place. Contact the City
FOI Coordinator, Deputy Clerk if you have any questions or concerns about this collection of information at 705-
324-9411 extension 1322.
Revision Date: April 15, 2009 12:59pm