HomeMy WebLinkAbout069 - Safety Suggestion Report Form ADMINISTRATIVE ORDER NO, 69
• TO: All Department
FROM: Gary Crutchfiel ager
DATE: April 26, 1993 `
SUBJECT: HAZARDOUS CONDITIONS/SAFETY SUGGESTION REPORT FORM
I. PURPOSE: This administrative order is issued to implement the use of the
hazardous conditions/safety suggestion form for the reporting of conditions and
practices jeopardizing public or work place safety, which are reported by
citizens or observed by city employees. The hazardous conditions/safety
suggestion form shall be included in the accident prevention program.
II. USE OF THE HAZARDOUS CONDITIONS/SAFETY SUGGESTION FORM:
A. Distribution: A supply of the hazardous conditions/safety suggestion form
shall be issued to all departments. It is particularly important that those
employees answering City telephones and likely to take calls from the public
reporting a hazardous or unsafe condition on City property or in the public
right-of-way have an adequate supply of the forms at their work stations for
the taking of citizen reports. It is also important that City employees
driving City vehicles have a supply of the forms in their vehicles to record
conditions that they may observe from time to time during their travels
• throughout the city.
B. Completion/Routing: Routing instructions are included on the back side of
each of the three sheets comprising the form. Section I of the form is to
be completed by the person taking the report from the citizen or by the
employee who is making a report from their own personal observation or
knowledge. The employee completing Section I distributes the copies as
follows:
a. The original (top sheet) goes to the Risk Manager (City Attorney).
b. The bottom two copies go to the appropriate department to complete
Section II. The appropriate department head means the department or
division of the department occupying or maintaining the property or work
location where the condition or practice is located.
After completing Section II, the department will retain the yellow copy and
send the pink copy to the Risk Manager for his final review and completion
of the report form.
ADMINISTRATIVE ORDER NO. 69 - PAGE 1
HAZARDOUS CONDITIONS/SAFETY SUGGESTION REPORT FORM
•
C. Resolution: If the condition or suggestion is resolved to the satisfaction
of the Risk Manager, the process shall be completed by the filing of the
completed form. If the Risk Manager believes that the matter requires
• corrective action not taken or needs further--.` estigation, the matter shall
be referred by the Risk Manager to the Loss Control Committee or to the City
Manager for determination whether further" action should be taken. If the
report involves a workplace safety suggestion, the Risk Manager shall send a
copy of the completed form to the Secretary of the City-wide Safety
Committee for review and discussion by the Safety Committee. The Safety
Committee may direct its questions or suggestions to the Risk Manager for
his response or referral to the Loss Control Committee.
D. Employee Safety Complaints: Employees are not to use this form as a
substitute for advising their own supervisors concerning conditions or
practices within their department or division which they believe to be
hazardous or unsafe to employees, or in violation of work place safety laws
or regulations. They should first attempt to follow the standard procedures
used in their department for the reporting of such conditions or practices.
In the event, however, that an employee feels that their safety suggestion
has not received appropriate handling at the department level, the employee
shall use the Hazardous Conditions/Safety Suggestion form following the
routing instructions set forth in this Administrative Order and file a copy
with the City-wide Safety Committee.
F . Incident Report Forms: In situations where an incident has occurred
requiring the completion of an incident report form (Administrative Order
. No. 53), any conditions believed to have contributed to the incident should
be reported in the incident report form and a hazardous condition/suggestion
report form is not required.
III. EFFECTIVE DATE: This order is effective immediately.
ADMINISTRATIVE ORDER NO. 69 - PAGE 2
HAZARDOUS CONDITIONS/SAFETY SUGGESTION REPORT FORM
HAZARD CONDITION / SAFETY SUGGESTION
Sections I and H must be completed and forwarded to Risk Manager within 3 days of date reported
See Reverse Side for Routing Instructions
section I (to be completed by person taking report)
PERSON REPORTING HAZARD OR SUGGESTION:
Name: Department:
Address: Phone:
NATURE OF REPORT: ❑ Employee Safety ❑ Public Safety
SPECIFIC INFORMATION:
A. Date Reported: Time:
B. Describe Location:
C. Describe the Hazard/Problem in Detail:
D. Name(s) of Person(s) Involved Address Phone
E. Witnesses (if none, write none) Address Phone
Information routed to: Department:
Completed by: Department: Phone:
Section II (To be completed by responding Department) Date received:
What corrective measures were taken or assistance given? (if none, please explain)
Completed by: / Date:
(Name) (Position)
Final Review (To be completed by Risk Manager) Date received:
Risk Manager