PSC-CUNY Health and Safety

Incident Report

O     Indoor Air Quality / Dust
O     Construction/renovation
O      Leaks/mold
O      Rodents

 

O  Heating/Air conditioning/temperature
O  Repairs needed: ceiling, floor, walls
O  Hygiene/dirt
O  Safety

O  Other ________________________

 

Campus:   ______________________________________________________________

Date reporting problem:  ___________________________________________________

Person /group reporting:   __________________________________________________ 

 Phones:________________________________________________________  

 Email: _____________________________________________________________

Nature of Complaint:    

Dates of occurrence:      ________________

Location:  (building, floor, room etc.) ________________________________________________________________________ 

Description of problem: ______________________________________________________________________________

______________________________________________________________________________

How many people affected?   _________________________ 

Health problems?     ________________________________________________________ 

Were Administrative personnel informed about complaint?    Yes___      No____

Who and when?  _____________________________________________

How informed?  (phone,  email,  memo) _________________________________________

  Please forward to

PSC/CUNY Environmental Health and Safety Watchdog Committee
61 Broadway 16th floor

New York, New York
212-354-1252/ fax:  212 302-7815
email: hswatchdogs@pscmail.org


Interested in working with the Environmental H&S Watchdogs at Brooklyn College? Contact Joan Greenbaum/Jean Grassman Co-chairs at hswatchdogs@pscmail.org

UPDATED 3/19/10