Report • CampusOptics

Please complete this form to nominate the individual that has shown commitment to improving safety in their workplace, laboratory, classroom, or campus environment.

The questions on this nomination form will help determine whether the nominee meets the criteria for the Safety Champion recognition so please complete all sections.

EH&S will review all nominations and notify selected recipients.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Anonymous Submission

This submission will be anonymous. No reporter information will be collected, but all of your responses and form information will be submitted.

Location

Name* Required

Additional Location Details

Exact Location

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Nominee Information

Name of Nominee* Required

Affiliation with William & Mary* Required

Reason for Nomination

Provide a description of the hazard or risk the nominee recognized or brought to attention.* Required

Please describe a situation where the nominee took action without being required to do so.* Required

Describe how the nominee demonstrated responsibility for their own safety and the safety of those around them.* Required

Please provide an example of the nominee encouraging or leading other to follow safe practices* Required

Describe how the nominee’s safety actions reflect William & Mary’s values of integrity, respect, service, and flourishing.* Required

Nominator Information

Date* Required

Your Name

Your Email Address

Your Affiliation with William & Mary* Required

Additional Context or Supporting Material

Optional

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.