Employee Safety Reporting Program Form

Non-punitive employee form for reporting safety concerns, hazards, near misses, and unsafe conditions to management as part of a Public Transportation Agency Safety Plan (PTASP).

Report Overview

• What are you reporting?
• Submit anonymously
  Select this if you do not want to provide your name or contact details. Do not include PII in the report narrative if you choose anonymous submission.
• Brief summary of the concern
• Date observed
• Time observed

Location and Asset Details

• Where did this occur?
• Location name or identifier
• Asset involved
  Select all that apply.
• Route, line, or service number

Safety Concern Details

• Describe the concern or event
• Primary hazard category
• Is there an immediate danger to employees, passengers, or the public?
• What immediate action was taken?
  Select all that apply.
• Contributing factors
  Select all that may have contributed.

Impact and Follow-Up

• Did anyone get injured or was there property damage?
• Injury severity
• Service impact
• Recommended follow-up or corrective action

Reporter Information and Consent

• Your name
• Your email
• Your phone number
• I consent to being contacted for clarification or follow-up on this report
  Your contact information will be used only for safety review and follow-up related to this submission.
• I understand this report is part of a non-punitive safety reporting process
  Reports are reviewed for safety improvement, not discipline, except where required by law or policy.