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Share a Concern

As part of a commitment to community safety, this form should be used to share a concern regarding an actual or potential workplace violence risk and any employee, friend/family member, customer, or other individual involved. We follow a strict no-retaliation policy and are committed to ensuring a safe workplace. We want to hear about any situation or behavior that raises a risk to anyone’s personal, physical, or emotional well-being.


When in doubt, fill this out. We would much rather receive a concern that we are already aware of or that doesn’t have violence potential than have an employee skip filling out this form and end up missing something we could have acted on.

Facility Safety Concern

Behavioral Safety Concern

Please check any behaviors that concern you about the situation, employee, or person(s) involved.

Environmental Circumstances:
Financial insecurity:
Concerning Behaviors:
Have you told the person that you will be submitting this referral?

I understand that referrals from this form will be received during regular business hours (Monday – Friday, 8:00 a.m. – 5:00 p.m.) and are not monitored after hours, on weekends, or during official holidays. I understand that if there is an immediate risk of harm to self or others, I should contact on-site security or the local police before submitting this form.

Are you comfortable with us letting those involved know you shared this concern?
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