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* 1. Name (Optional)

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* 2. Contact information (Optional)

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* 3. Please list any safety concerns you would like us to share with the department. (If sharing a particular incident, the more specific details, the better. Ex. where, when, time, etc.)

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* 4. Do you have any proposed solutions for any current issues regarding safety you would like us to share with the department? (Please be specific.)

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