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EMERGENCY NOTICE: Do
Not Report an Emergency Using this Form or Email!

To report an emergency, fatality, or imminent
life threatening situation
please contact our toll free number
immediately:

1-800-321-OSHA (6742)

TTY
1-877-889-5627

Please fill out sections 1 through 19, but READ THIS
first.
Items noted with an asterisk (*) are required in order to accept your
submission.

* 1. Establishment
Name:

NOTE: In order for OSHA to fully
process your complaint, complete and accurate information about the
worksite is necessary.

* 2. Site
Street:

* 3. Site
City:

* 4. Site
State: Select A
StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict
of
ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew
YorkNorth CarolinaNorth
DakotaOhioOklahomaOregonPennsylvaniaPuerto
RicoRhode IslandSouth CarolinaSouth
DakotaTennesseeTexasUtahVermontVirgin
IslandsVirginiaWashingtonWest
VirginiaWisconsinWyoming

* 5. Site
ZIP Code:

6. Mailing
Address
(if different):

7. Management
Official:

8.
Telephone Number:

9. Type of
Business:

* 10. Hazard
Description.

Describe briefly the hazards(s) which
you believe exist.Include the approximate number of employees exposed to
or threatened by each hazard:

* 11. Hazard
Location.

Specify the particular building or
worksite where the alleged violation exists:

12. This condition has been brought to the attention of: (Choose
all that apply)

Employer
Other Government Agency
(specify)

13. I am a(n):

Employee
Federal Safety and Health Committee
Representative of Employees
Other: (specify)

The OSH
Act gives complainants the right to request that their names not be
revealed to their employer. Providing your name and address, will only
allow OSHA staff to communicate with you regarding your complaint.

14. Please indicate your desire:

Do NOT reveal my name to my
Employer
My name may be revealed to my
Employer

* 15. Complainant Name:

* 16. Complainant
Telephone Number:

17. Complainant Mailing
Address

Street:

City:

State:
Select A
StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict
of
ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew
YorkNorth CarolinaNorth
DakotaOhioOklahomaOregonPennsylvaniaPuerto
RicoRhode IslandSouth CarolinaSouth
DakotaTennesseeTexasUtahVermontVirgin
IslandsVirginiaWashingtonWest
VirginiaWisconsinWyoming

ZIP Code:

18. Complainant
E-Mail Address:

19. If you are an authorized representative of employees affected
by this complaint, please state the name of the organization that you
represent and your title:

Organization
Name:

Your Title:

Punishment for Unlawful
Statements

Potential complainants also should keep in mind
that it is unlawful to make any false statement, representation, or
certification in any complaint. Violations can be punished under Section
17(g) of the OSH Act by a fine of not more than $10,000, or by
imprisonment of not more than 6 months, or by both.

Public reporting burden for this voluntary
collection of information is estimated to vary from 15 to 25 minutes
per response with an average of 17 minutes per response, including
the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. An Agency may not
conduct or sponsor, and persons are not required to respond to the
collection of information unless it displays a valid OMB Control
Number. Send comment regarding this burden estimate or any other
aspect of this collection of information, including suggestions for
reducing this burden to the Directorate of Enforcement Programs,
Department of Labor, Room N-3119, 200 Constitution Ave., NW,
Washington, DC; 20210.

OMB Approval# 1218-0064; Expires:
03-31-2011

DO NOT SEND THE COMPLETED FORM TO THIS
OFFICE.

Freedom of Information
Act  |  Privacy & Security
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Contact Us

U.S. Department of Labor  |  Occupational Safety
& Health Administration  |  200 Constitution Ave., NW, Washington,
DC 20210
Telephone: 800-321-OSHA (6742)  |  TTY: 877-889-5627
http://www.osha.gov/