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Return to the
Online Complaint Form

For the General Public
This form is provided for the assistance
of any complainant and is not intended to constitute the exclusive means
by which a complaint may be registered with the U.S. Department of
Labor

Sec 8(f)(1) of the Williams-Steiger Occupational Safety and Health Act,
29 U.S.C. 657, provides as follows: Any employees or representatives of
employees who believe that a violation of a safety or health standard
exists that threatens physical harm, or that an imminent danger exists,
may request an inspection by giving notice to the Secretary or his
authorized representative of such violation or danger. Any such notice
shall be reduced to writing, shall set forth with reasonable particularity
the grounds for the notice, and shall be signed by the employee or
representative of employees, and a copy shall be provided the employer or
his agent no later than at the time of inspection, except that, upon
request of the person giving such notice, his name and the names of
individual employees referred to therein shall not appear in such copy or
on any record published, released, or made available pursuant to
subsection (g) of this section. If upon receipt of such notification the
Secretary determines there are reasonable grounds to believe that such
violation or danger exists, he shall make a special inspection in
accordance with the provisions of this section as soon as practicable to
determine if such violation or danger exists. If the Secretary determines
there are no reasonable grounds to believe that a violation or danger
exists, he shall notify the employees or representative of the employees
in writing of such determination.

NOTE: Section 11(c) of the Act provides explicit protection for
employees exercising their rights, including making safety and health
complaints.

For Federal Employees
This report format is provided to assist
Federal employees or authorized representatives in registering a report of
unsafe or unhealthful working conditions with the U.S. Department of
Labor.

The Secretary of Labor may conduct unannounced inspections of agency
workplaces when deemed necessary if an agency does not have occupational
safety and health committees established in accordance with Subpart F, 29
CFR 1960; or in response to the reports of unsafe or unhealthful working
conditions upon request of such agency committees under Sec. 1-3,
Executive Order 12196; or in the case of a report of imminent danger when
such a committee has not responded to the report as required in Sec.
1-201(h).

Instructions
Fill in the form as accurately and completely as
possible. Describe each hazard you think exists in as much detail as you
can. If the hazards described in your complaint are not all in the same
area, please identify where each hazard can be found at the worksite. If
there is any particular evidence that supports your suspicion that a
hazard exists (for instance, a recent accident or physical symptoms of
employees at your site) include the information in your description.

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: 03-11-2011

DO NOT SEND THE COMPLETED FORM TO THIS
OFFICE

Return to the
Online Complaint Form

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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/