Employee Safety Suggestion
and Action Record

One concern, a traceable response and a check of the result.

Developed by Todd Jerome Jenkins, MS, CSP · Edition 1 · October 26, 2026

Urgent concerns: use your workplace’s prompt hazard-reporting, escalation or emergency process. Do not wait for routine suggestion review. The worker does not need to propose a solution.

1. Capture the concern

Record identifier / date received

Work area / task / shift

What is happening? What concern or opportunity should be considered?

What conditions make it difficult, or help the work go well?

Suggested response, if any — optional

Reporter / preferred reply route — optional

Acknowledged by / date / next update

Provide an anonymous reporting route where available. Do not include unnecessary medical or personnel details. Share status summaries without identifying the reporter.

2. Assess and assign

Urgency / potential exposure / assessment by and date

Immediate response, interim protection and escalation, if needed

Accountable action owner / authority or escalation route

Affected workers involved / further assessment needed

Employee Safety Suggestion and Action Record · Edition 1

3. Plan, implement and verify

Record identifier

Current status / date / next review

Suggested statuses: received · under assessment · action planned · in progress · awaiting verification · verified closed. Record a reason and review plan for an alternative, declined proposal or deferral. An unresolved hazard still needs a response.

Actions and follow-up
Action / resources needed	Owner / target date	Completion evidence / date

Verification plan: what should change, how will it be checked, under which conditions, and by whom?

Verification findings / evidence reference / date

Worker feedback / remaining concerns / whether to revise or reopen

Decision and reasons / responsible reviewer / date / next check

Feedback communicated: what changed, what remains, how and when shared

Before closure: check the response against the original concern. A work order, purchase or training attendance record alone does not verify effectiveness. Select a competent inspection, measurement or other method suited to the actual issue.