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2. Description

   This is the Fire & EMS Safety Suggestion Box. This is a depot to hear about near misses or other ways that we can improve safety throughout the system

4. First Name*
5. Last Name*
7. Email*
9. Phone Number*
10. Agency*

    1. Blue Ridge
    2. Troutville
    3. Buchanan
    4. Fincastle

    1. Eagle Rock
    2. Glen Wilton
    3. Read Mountain
    4. County Staff
14. Safety Suggestions
16. Suggestion Category*

    1. Equipment failure/concern
    2. Near miss
    3. Personal Protective Equipment
    4. Station concern
    5. Apparatus concern
    6. Other
18. Safety Concern/Potential Hazard*
20. Recommendation / Suggested Corrective Action
22. Supervisor’s Name
23. Have You Notified Your Supervisor?

    1. Yes
    2. No
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field