INSTRUCTIONS

I. EMPLOYEE (Print, sign, and date.) a. Complete section I. and file it with your immediate supervisor. b. If you desire anonymity, complete section I. (including your name) and file the report with the Safety Office. Safety personnel will immediately return the form to your supervisor for necessary action, and will delete your name from the form to ensure your anonymity.

II. SUPERVISOR (Print, sign, and date.) a. Investigate the alleged hazard during the same tour of duty in which the report was received. b. Abate the hazard if it is within the scope of your authority to do so. c. Record the action taken to eliminate the hazard or record recommendations for corrective action in section II. and sign your name. d. Forward the original and yellow copy to your immediate supervisor (approving official); send the pink copy to the Safety Office; and give the employee the remaining blue copy as a receipt. It is your responsibility to monitor the status of the report, at all times, until the hazard is abated.

III. APPROVING OFFICIAL (Print, sign, and date.) a. Initiate action to eliminate or minimize the hazard. If this results in the submission of a work order, attach the original of this form, and forward through channels, to the manager, Plant Maintenance. b. If you determine that there are no reasonable grounds to believe a hazard exists, notify the employee in writing within 15 calendar days. Safety personnel will assist you in this determination when requested. c. If the hazard was abated by the first line supervisor or when it has been abated through your actions, notify the employee in writing, and send the original of this form to the Safety Office.

IV. MAINTENANCE SUPERVISOR (Print, sign, and date.) When the work order has been completed, sign, date, and return the original of this form to the approving official who will then forward it to the Safety Office