New York Army National Guard Safety

Report A Workplace Safety Hazard

This form can be used by New York Army National Guard members to report unsafe conditions in the workplace.

The purpose of this form is to maintain a safe and productive work environment by helping to prevent accidents, damage to property/equipment, injuries, illness, or fatalities.

Contact Information

You are not obligated to provide contact information, however submitting this form anonymously may delay resolution of the hazard. We will also not be able to contact you with any progress updates. Please provide your contact information below, or leave all of the fields in this section blank to send this report anonymously.

Name: Rank/Title: Email: Phone:

Hazard Information Which best describes the hazard: Location Type: Date Observed: Building/Facility Address/Name (if known): Additional Details Please provide any other information concerning this hazard: Check this box if you have already reported this hazard