CORRECTION OPPORTUNITY

YOU COULD WIN A $25.00 VISA CARD FOR YOUR “NEAR MISS”!

 

Employee’s Name:  _______________________________________________

Date of event: ____________________

What happened:_____________________________________________________________

What I learned/would have done differently/changes that might be helpful:

_____________________________________________________________________ 

                                                                                                                                                                                                                   
Employee’s Signature ___________________________________                                                                                                    

                                                                                                           

Department Head’s Signature_______________________________________

 

Please, give your completed form with photo, if possible, to any Safety Committee member or Nancy Hamilton, the Safety Coordinator at Cell (406)230-0922, fax (406)228-9027,  or e-mail: nhamilton@valleycountymt.gov,
mailing address: 501 Court Square, Glasgow, MT  59230.  Completed forms will be reviewed at the next month’s Safety Committee meeting.  Chances of winning will depend on number of entries and the Committee’s judgment of quality and substance.  All decisions are final.  Entrant will be contacted if they win.