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OSHA
Online Complaint Form
Notice
of Alleged Safety or Health Hazards
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
|
|
|
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Please fill out
sections 1 through 19, but READ
THIS
first.
Items noted with an asterisk (*)
are required in order to accept your submission.
|
|
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of Form
*
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:
*
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):
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:
This
constitutes my electronic signature.
(If
this box is checked, this submission shall be considered as an
authorized written signature.)
*
16. Complainant Telephone Number:
17.
Complainant Mailing Address
Street:
City:
State:
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:
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|
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: 05-31-2014
DO
NOT SEND THE COMPLETED FORM TO THIS OFFICE.
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of Information Act
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& Security Statement
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Web Site Notices
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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
www.OSHA.gov
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Smyth, Michel - OASAM OCIO |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |
