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: __________________________