Public Transportation Cleaning Refusal Form
Use the Public Transportation Cleaning Refusal Form to document instances when a passenger refuses a requested cleaning, sanitation, or cleanup action on any public transportation vehicle or area.
Staff Member Name
*
First Name
Last Name
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (Vehicle, Station, or Area)
*
Type of Cleaning or Sanitation Requested
*
Please Select
Seat cleaning
Floor cleaning
Trash removal
Sanitizing surfaces
Other
Brief Description of Refusal Incident
*
Passenger Description (e.g., gender, approximate age, clothing)
Area or Seat Number (if applicable)
Action Taken by Staff
*
Please Select
Informed passenger of policy
Notified supervisor
No further action
Other
Supervisor Notified
Yes
No
Additional Comments
Submit Refusal Record
Should be Empty: