Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 5 19 of 53 8 BOP Belt e rra Ob ser v a tio n Pr og ra m to pre v en t u ns a fe b eh a v io rs at w ork Doc u m e n t Identif icat ion F R M 047 P age Nu m b e r 1 of 2 Doc u m e n t C r e ation Dat e S e ptembe r 15 2014 Im p le m e n tat ion Dat e S e ptembe r 30 2014 HEALTH S A FETY CO NC E R N FO R M This for m i s to b e use d by e mpl o y e e s who w ish t o re port H S prob lem un sa fe wo rk c ondit ion or pr a c ti c e voice H S c onc e rn or t o pro vide a sa fe t y su gg e s ti on Your a ssi stanc e in i nfor mi ng us a bout s uc h c onc e rn s is esse nti a l t o pro vide a s a fe r wor k e nvironm e nt at B e lt e r ra On c e c ompl e t e d ha nd thi s for m over t o y our supe rvisor or the sa fe t y r e pre se nt a ti ve P lea se pra c ti c e e ti que tt e whe n fil li ng in t he fo rm ie do not bl a me or a tt a c k a n y indi vidual but addr e ss t he sit ua ti on or c onc e rn itself An y fr ivol ous or f r a udu lent subm iss ions wi ll no t be tol e ra ted Des c ription of uns a f e c ondit ion pra c ti c e o r c once rn Inc l ud e what y o u be l i ev e r ea l l y c au s e d o r wi l l c au s e the pro bl em or an i s s ue A tt ac h a d di t i on al s h ee t i f ne c e s s ar y Chec k m ar k he r e i f y o u be l i e v e y o ur c on c ern ne e ds i m m ed i ate r e v i e w an d res o l ut i on Caus e s or other c o nt ributing fac to rs Im p ro p e r t o o l I m p ro p e r o r l a ck o f PPE L a ck o f t o o ls o r e q u ipmen t Im p rop e r train ing Ot h e r p lea s e sp e ci f y W ha t do y ou be li e v e ma y be the c onse que nc e s if y our c once rn re ma in s uns olv e d Dam a g e o r l o ss o f m a ch i n e ry e q u ipm e n t t o o ls In jury t o w o rker s L o ss o f li f e Ot h e r S p e ci f y