RISK MANAGEMENT SAFETY REPORT
 
Safety is of upmost importance for all staff and visitors of Montgomery County. The Montgomery County Department of Risk, Safety, and Emergency Management wants to ensure that all safety related concerns are addressed in a timely and appropriate manner. This form was created to address safety and risk concerns on properties that are maintained by Montgomery County. If you have questions about a situation and are unsure who to contact, please call 937-225-5472 for immediate assistance.
 
* = Required Field
* TYPE REPORT:              * Incident Type:  
 
Name

 
Address (Provide work address if employee)

 
Phone

Best time to Call:
 
* Email

 
* Address Where Incident Occurred

 
* Date of Incident

 
Time of Incident/Noticed Concern

 
Emergency Services Called
 
List the names of those involved:

Person 1

Person 2

Person 3

Person 4

*Please describe the Incident or Safety Concerns (4000 characters or less):
 
 

08/17/2022 01:29:16