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)


  
PSC-CUNY Health and Safety Watchdog Committee
25 W. 43rd St.  5th Floor
NYC 10026
212-354-1252/ fax:  212 302-7815
email: jgreenbaum@pscmail.org

Local Campus Watchdog committee contact: __________________________