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ANONYMOUS UNSAFE CONDITION OR UNSAFE ACT REPORT

COMPLETE ALL SECTIONS – ATTACH ADDITIONAL SHEETS IF NECESSARY REPORT SHOULD BE MAILED OR SENT VIA INTER-OFFICE. MAIL TO: DIRECTOR, RISK MANAGEMENT, SAFETY & POLICE, RIVERSIDE COMMUNITY COLLEGE DISTRICT, 3801 MARKET ST., RIVERSIDE, CA 92501.

IMMEDIATE ACCIDENT / INCIDENT CAUSE(S)

UNSAFE ACTS

In your opinion, what is causing the unsafe condition or act?
(Choose one or more)

UNSAFE CONDITIONS

In your opinion, why do these conditions exist?
(Choose one or more)

ROOT CAUSES

NOTE: The RCCD Risk Management, Safety & Police Department is committed to the safety and security of all students, faculty, and staff. Every report of an unsafe act or unsafe condition will be investigated and every effort to resolve the deficiency will be taken. ALL results from the investigation will remain confidential. The RMSP Department will not release the outcome of the investigation to the reporting party. This document is intended to serve as a one-way report of an unsafe act or unsafe condition so that RMSP can investigate and take action to notify the appropriate management personnel of the issue.

NOTE: It is unlawful to make any false statement, representation or certification in any document filed pursuant to the Occupational Safety and Health Act of 1970. Violations can be punished by a fine of not more than $10,000 or by imprisonment of not more than six months, or by both. Section 17(g).

Date
8/7/2020
THIS REPORT IS PRIVILEGED AND CONFIDENTIAL UNLESS THE COMPLETING PARTY AGREES TO WAIVE THEIR ANONYMITY IN WRITING BY COMPLETING THE NAME AND CONTACT SECTIONS ABOVE.

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