Title Page
MU S643 Notice of Equipment /System Deficiency
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Please use this form of you have any safety concerns, equipment malfunctions or potential problems, or suggestions which will improve our work environment.
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Deficiency (please be specific):
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Add media
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Proposed solution or suggestions:
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Submitted to supervisor by:
Follow-up
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Action taken:
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By:
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__________ Original to Regional Safety Coordinator if safety Related
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__________ or Original to Department Manager
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__________ Copy to employee