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