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Environmental Health and Safety Unsafe Condition Report Form

Rensselaer's Unsafe Condition Reporting Program is a proactive way to help reduce future incidents, accidents or injuries. If you see something you think may be unsafe on either the Troy campus or the Hartford campus location, please take time to fill out this form and send it to Environmental Health and Safety. If you wish, you may print the form and mail it to the following address:

Environmental Health and Safety
Division of Human Resources Rensselaer Polytechnic Institute
21 Union St. 2nd floor
Troy NY 12180

You may also simply submit it on-line to automatically send it to Rensselaer's Environmental Health and Safety staff.

Your concerns are important to us! We strongly encourage you to include your name and contact information, as this will allow for us to follow up with you in case there are additional questions regarding the condition you are reporting. While optional, if you provide us your name and contact information, we'll let you know how we've addressed your concern.

Please do not use this form to report an emergency or an immediate life-threatening hazard. To report immediate emergencies on the Troy campus, call Public Safety at 276-6611; on the Hartford campus, dial 911.

Also do not use this form to report an injury or illness sustained on the job. Please use HR's Incident Report Form for this purpose.


* Date:
Submitted by:
* Institute affiliation: Faculty/staff
Student
Visitor
Phone number:
* Please describe what you saw, and why
you think it is an unsafe condition:
* Location of unsafe condition (please be as
specific as possible:
* What recommendations do you have for fixing
this unsafe condition?