Form OSHA 8-60.1 OSHA 8-60.1 Notice of Whistleblower Complaint

Notice of Whistleblower Complaint

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US Department of Labor

OMB # 1218-0236

Occupational Safety and Health Administration
Notice of Whistleblower Complaint
INFORMATION ABOUT FILING A WHISTLEBLOWER OR RETALIATION COMPLAINT WITH OSHA
FOR ALL EMPLOYEES:
OSHA administers the whistleblower protection provisions of more than twenty whistleblower protection statutes, including Section 11(c) of the Occupational Safety and
Health (OSH) Act, which prohibits any person from discharging or in any manner retaliating against any employee because the employee has complained about unsafe
or unhealthful conditions or exercised other rights under the Act. Whistleblower protection provisions administered by OSHA also protect employees from retaliation for
reporting violations of various airline, commercial motor carrier, motor vehicle safety, consumer product, environmental, consumer finance, food safety, health
insurance reform, nuclear, pipeline, public transportation agency, railroad, maritime and securities laws.
Each law requires that complaints be filed within a certain number of days after the alleged retaliatory action; the time periods vary from 30 days to 180 days. For
example, Section 11(c) of the OSH Act requires that a complaint be filed within 30 days of the alleged retaliatory action and the International Safe Container Act
requires that a complaint be filed within 60 days of the action. Visit the Whistleblower Protection Programs' website at www.whistleblowers.gov, or call 1-800-321-OSHA
(6742), for more information about these time limits.
A complaint of retaliation filed with OSHA must allege that the employee engaged in activity protected by the whistleblower provisions (such as reporting a violation of
law), the employer knew about or suspected that activity, the employer subjected the complainant to an adverse action or threatened such action, and the protected
activity motivated or contributed to the adverse action. Adverse actions include discharge, demotion, blacklisting, denial of promotion, harassment and generally any
other action that would dissuade a reasonable employee from engaging in protected activity.
Upon receipt of a complaint, OSHA will contact the complainant to determine whether to conduct an investigation. It is very important that a complainant respond to
such contact; if a complainant is unresponsive, OSHA cannot proceed with an investigation and the complaint will be dismissed. If OSHA proceeds with an investigation,
the complainant will have an opportunity to offer documents and other evidence in support of the complaint, and the employer will be notified of the allegation and
permitted to submit a response.
BY LAW, A COMPLAINANT'S INFORMATION, INCLUDING HIS/HER IDENTITY, MUST BE PROVIDED TO THE EMPLOYER. A WHISTLEBLOWER
COMPLAINT FILED WITH OSHA CANNOT BE FILED ANONYMOUSLY.
If, after an investigation, the evidence supports the complainant's allegation and a settlement cannot be reached, OSHA will generally issue an order requiring that the
complainant be reinstated and paid back pay and damages, if appropriate, which the employer may contest. In cases under the Occupational Safety and Health Act,
Asbestos Hazard Emergency Response Act, and the International Safe Container Act, the Secretary of Labor may file suit in federal district court to obtain relief. Under
other statutes, the Secretary may order relief for the complainant, but the employer may contest that decision before an administrative law judge.
FOR PUBLIC-SECTOR EMPLOYEES:
Coverage of public-sector employees varies by statute. If you are a public-sector employee and you are unsure whether you are covered under one or more of the
whistleblower protection statutes that OSHA administers, call 1-800-321-OSHA (6742) for assistance, or visit www.whistleblowers.gov.
With the exception of employees of the U.S. Postal Service, public-sector employees (those employed as municipal, county, state, territorial or federal workers) are not
covered by the Occupational Safety and Health Act. Non-federal public-sector employees may be covered in states which operate their own occupational safety and
health programs approved by Federal OSHA. For information on the 27 federally approved State Plan States, call 1-800-321-OSHA (6742) or visit
www.osha.gov/dcsp/osp/index.html.
All Federal agencies are required to establish procedures to assure that no employee is subject to retaliation or reprisal for the types of activities protected by Section
11(c). A federal employee who wishes to file a complaint alleging retaliation due to disclosure of a substantial and specific danger to public health or safety or involving
occupational safety or health should contact the Office of Special Counsel - visit www.osc.gov.
Federal employees should also contact their agency's Designated Agency Safety and Health Officer (DASHO). See 29 C.F.R. 1960.6 for more information regarding
DASHOs.
For assistance filing a complaint with a DASHO, federal employees may contact OSHA's Office of Federal Agency Programs. For contact information, visit
www.osha.gov/dep/enforcement/dep_offices.html.

INSTRUCTIONS TO COMPLETE FORM
It is not necessary to use this form. OSHA will accept whistleblower complaints made orally (telephone or walk-in) or in writing, and in any language.
For your form to be properly filed, you must complete the fields that are marked as "required." Fields not designated as "required" are optional, but you are encouraged
to complete the form as completely and accurately as possible. Briefly describe each allegation of retaliation (what happened?). If there is any particular evidence that
supports your allegation, include the information in your description. If there is not enough space on the form, use the continuation sheets. However, as noted above,
information contained in this complaint will be shared with the employer. Therefore, DO NOT INCLUDE WITNESS NAMES OR THEIR CONTACT INFORMATION

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ON THIS FORM OR IN YOUR INITIAL COMPLAINT FILING.
After you have completed the form, you may submit it to OSHA by clicking "send" at the bottom of the form. You may also print the form and submit it to OSHA office
by mail, fax, or hand-delivery. Contact 1-800-321-OSHA (6742) or visit www.osha.gov to locate a local OSHA office.
After you submit this form to OSHA, an OSHA representative will contact you.
PRIVACY ACT STATEMENT
This form requests personal information that is relevant and necessary to determine whether and how to conduct an investigation. OSHA collects this information in
order to process complaints under its statutory and regulatory authority. Once a complaint is filed, the individual's name and information about the allegations of
retaliation will be disclosed to the employer. During the course of an OSHA investigation, information contained in an investigative case file may be disclosed to the
parties in order to resolve the complaint. During an investigation, information about the complaining party and the employer will not be released to the public except to
the extent allowed under the Freedom of Information Act (FOIA). However, once a case is closed, it is possible that information contained in the complaint or a case
file may be released to the public as required by the FOIA. Any such documents will be redacted as appropriate under the FOIA and the Privacy Act.
PAPERWORK REDUCTION ACT STATEMENT
According to the Paperwork Reduction Act, an Agency may not conduct or sponsor, and no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. Public reporting burden for this voluntary collection of information is estimated to be one hour 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the
Directorate of Whistleblower Protection Programs, Department of Labor, Room N4624, 200 Constitution Ave., NW, Washington, DC; 20210; Attn: Paperwork Reduction
Act Comment. (This address is for comments only; do not send completed complaint forms to this office.)
OMB Approval # 1218-0236; Expires: 05-31-2014

PART 1 - EMPLOYEE INFORMATION
1. Name (last, first, middle initial) (required):

2. Present Address (Street, City, State, Zip) (required):
Street:
City:

State:

Zip:

3. Telephone Numbers (include area code) (at least one required):
Home: ex. (###-###-####)

Work: ex. (###-###-####)

Cell: ex. (###-###-####)

4. Email Address:

5. Preferred Method of Contact:
6. Best time to be contacted (include time zone):
7. Work Site Address at Place of Employment where Alleged Retaliation Occurred (Street, City, State, Zip):
Street:
City:

State:

Zip:

8. Date of Hire at Place of Employment where Alleged Retaliation Occurred: ex. (mm/dd/yyyy)
9. Job Title at Place of Employment where Alleged Retaliation Occurred:

10. Exclusive bargaining (union) representative (if any):
Yes
No
I don't know
11. The person filing this complaint is (check one box):
Employee

Representative of Employee

Other (specify)

If you are an authorized representative of the complainant, please complete Part 4 - Identification of Representative.
PART 2 - EMPLOYER INFORMATION
12. Employer Name (required):

13. Name and Title of Management Person (for contact purposes only):
Name:

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Title:

Phone: ex. (###-###-####)
14. Name and Title of Supervisor:
Name:

Title:

15. Employer Mailing Address (if different from worksite address in #7):
Street:
City:

State:

Zip:

16. Employer Phone: ex. (###-###-####)
17. Employer Fax: ex. (###-###-####)
18. Employer Email:

19. Type of Business:

PART 3 - ALLEGATION OF DISCRIMINATION/RETALIATION

Please answer the questions below in the space provided. If you need additional space, use the attached "Continuation Sheet."
20. What management person is responsible for the retaliation that you are reporting?
Name:

Position/Title:

21. What are the actions or events that you are reporting to OSHA? You may check one or more of the boxes below, and/or describe the action(s) in the space
provided. (required)
Termination

Discipline

Demotion/Reduced Hours

Denial of Benefits

Failure to Promote

Negative Performance Evaluation

Failure to Hire/Re-Hire

Harassment

Suspension

Threat to Take any of the Above Actions

Other (please describe):

22. When did the employer take these actions against you? Please list all relevant date(s), ex. (mm/dd/yyyy), to the best of your recollection. If you cannot
remember the exact date(s), please put the approximate date(s).

23. When did you first learn that the action(s) would be taken against you? Please list all relevant dates(s), ex. (mm/dd/yyyy), to the best of your recollection. If
you cannot remember the exact date(s), please put the approximate date(s).

24. What reason(s) did the employer give you for each of these actions?

25. Why do you believe the employer took these actions against you? You may check one or more of the boxes below, and/or describe the reason in the space
provided.
Called/Filed with OSHA

Called/Filed with Another Agency

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Complained to Management

Reported an Accident or Injury

Participated in Safety and Health Activities
Refused to Perform Task (please specify reason for refusal)

Testified or provided statement in investigation or other proceedings (please specify)

Other (please describe)

26. For any of the actions you listed in #25, please provide the relevant date(s), ex. (mm/dd/yyyy), you engaged in that activity.

27 Do you believe the employer knew you engaged in the activity described in #25? If so, how do you think they learned of it?

28. Have you filed any previous complaints against this employer with OSHA regarding these or similar retaliatory actions?
Yes

No

If yes, please provide the complaint number and date filed.
Complaint Number:
Date filed: ex. (mm/dd/yyyy)
29. Have you taken any other action(s) to appeal, grieve, or report this matter under any other procedure?
Yes

No

If yes, please list the agency/organization(s) with whom you have appealed/grieved/reported this matter, the date filed, the current status of the procedure, and
any outcome:

30. How did you first become aware that you could file a complaint with OSHA?
OSHA Website

OSHA Poster

News story

OSHA Representative

Union

Other (please describe):

PART 4 - IDENTIFICATION OF REPRESENTATIVE

Complete this part if you are an authorized representative of the complainant. If an investigation is opened, you will be asked to submit a signed Designation of
Representative Form that will be sent to you.
If you are filing this complaint on your own behalf, do NOT complete this part.
Name:

Title:

Organization Name (if any):

Union Affiliation (if any):

Address (Street, City, State, Zip Code):
Street:

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City:

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State:

Zip:

Phone (day): ex. (###-###-####)
Phone (cell): ex. (###-###-####)
Email:
By checking this box, I certify that the named employee has authorized me to act as their representative for purposes of this complaint.
PART 5 - CERTIFICATION
NOTE: It is unlawful to make any materially false, fictitious, or fraudulent statement to an agency of the United States. Violations can be
punished by a fine or by imprisonment of not more than five years, or by both. See 18 U.S.C. 1001(a); 29 U.S.C. 666(g).
By checking this box, I certify that the information in this complaint is true and correct to the best of my knowledge and belief.
Date: ex. (mm/dd/yyyy)
CONTINUATION SHEET
Page No.
Part No.

of

Item/Question No.

Response Continuation

Send

Clear
OSHA 8-60.1 (Rev.1/13)

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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

www.OSHA.gov

http://draft.osha.gov/dep/whistleblower-complaint-form.html

5/2/2013