Contact Ombudsman

Request For Resolution Form

THIS FORM IS NOT TO BE USED IN EMERGENCY SITUATIONS. PLEASE CALL YOUR LOCAL EMERGENCY SERVICES OR DIAL 911.

Organization Information

THIS BOX MUST BE CHECKED TO PROCEED *
I have read and understand the Terms and Conditions and I wish to continue with this request for resolution form. Click here for Terms and Conditions

Agree

Company Name *

Address *

Employee Information

The Safety Ombuds program gives employees the right to request that their names not be revealed to their employer. Providing your name and contact information only allows Safety Ombuds consultants to communicate with you regarding your request for resolution.

Employee Name *

Please indicate a preference:
My name MAY be revealed,Please do NOT reveal my name,
Address *
What is your status with this company?

Currently employedPreviously employed

Report Details

Select option(s) that applies

Safety,Health,Environmental,Human Resources (i.e. discrimination, ethicial violations, violence, ect...)

Description of the issue(s):
Incident Location:
Please specify the date the incident took place

Please specify the time the incident took place
The issue(s) has been brought to the attention of:
Select all that apply:

Immediate Supervisor,Management,Government Agency,Safety Ombuds is my first contact

Verification

Who We Are

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Safety United is not just a training or consulting firm, WE ARE YOUR SAFETY DEPARTMENT. Our safety services have benefited thousands of employees and hundreds of employers saving companies hundreds of thousands of dollars through a proactive approach..

How can we help you?

Develop a Safety Culture in your organization