OSHA 8-60.1 Notice of Whistleblower Complaint

Notice of Whistleblower Complaint

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US Department of Labor
Occupational Safety and Health Administration
Notice of Whistleblower Complaint

OMB # 1218-0236

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.

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Notice of Whistleblower Complaint

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 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.

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Notice of Whistleblower Complaint

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: 07-31-2016

PART 1 - EMPLOYEE INFORMATION

Required fields denoted by *

1. Name (last, first, middle initial)*:

2. Present Address (Street, City, State, Zip)*:
Street*:
City*:
one...
Select
one...
State *: Select

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

Ext

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

4. Email Address:

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Notice of Whistleblower Complaint

one...
5. Preferred Method of Contact: Select
Select
one...

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:
Select
one...
State: Select
one...

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):

11. The person filing this complaint is (check one box):

Yes

No

Employee

I don't know

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*:

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

Name:

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Notice of Whistleblower Complaint

Title:

Phone: ex. (###-###-####)
(

)

Ext

14. Name and Title of Supervisor:

Name:

Title:

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

Street:

City:
one...
Select
one...
State: Select

Zip:

16. Employer Phone: ex. (###-###-####)
(

)

Ext

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."

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Notice of Whistleblower Complaint

20. What management person is responsible for the retaliation 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. )
Termination
✔ Denial of Benefits
✔ Failure Hire / Re-hire
✔ Threat to Take any of the Above Actions
✔

Discipline
Failure to Promote
✔ Harassment
✔ Other (please describe)
✔

✔

Demotion / Reduced Hours
✔ Negative Performance Evaluation
✔ Suspension
✔

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, 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 date(s), ex. (mm/dd/yyyy),
to the best of your recollection. If you cannot remember the exact date, 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.

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Notice of Whistleblower Complaint

Called / Filed with OSHA
Complained to Management
✔ Participated in Safety and Health Activities
✔

✔

✔

✔

Called / Filed with Another Agency
Reported an Accident or Injury

✔

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?
If yes, please list the agency/organization(s) with whom you have appealed/grieved/reported this matter, the date filed, the

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Notice of Whistleblower Complaint

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:

City:
one...
State: Select
Select
one...

Zip:

Phone (day): ex. (###-###-####)

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Notice of Whistleblower Complaint

(

)

Ext:

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.
✔

Continuation Sheet
Please reference Part No. and Item/Question No. when providing response continuation.

Send

Clear

Warning
This complaint information will be cleared and cannot be recovered.
Are you sure?
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

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Notice of Whistleblower Complaint
Telephone: 800-321-OSHA (6742) | TTY
www.OSHA.gov

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