• Who has the issue or complaint?

  • Enter date

  • Is this a complaint (operator brought up an issue about a specific part of a station or job job) or an incident (an event happened resulting in injury)?

  • Did the operator report this issue before?

  • Enter a brief but detailed description of issue or complaint.

  • Station Name

  • If other was selected please enter station/area below

  • Please select which body part(s) are causing the problem (Check all that apply)

  • Who was the issue/complaint reported to?

  • Have you been rotated from this station previously?

  • Person who has issue or complaint please sign below.

  • Prison who is filling out report sign below

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.