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2. You are encouraged to report unsafe conditions that you observe on Ellis County properties.
   This form should not be used to report situations that require immediate attention. Should a problem require urgent attention, please call (785) 628-9410. Thank you for your assistance!
4. Description of Safety Hazard/Concern.*
6. When was the Safety Concern observed?
8. Month*
10. Day*
12. Year*
14. Time*
16. Location*
18. If available, please attach a photo of safety/hazard issue.
20. If you would like for someone to follow-up with you, please complete the following information.
22. Name
24. Phone Number
26. Email
Leave This Blank:


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

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field