Hazardous Conditions Complaint Screen Shot Update

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Mine Safety and Health Administration
   MSHA - Protecting Miners' Safety and Health Since 1978
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Hazardous Condition Complaint
Step 1: Contact Information > Step 2: Complaint Information > Step 3: Summary

OMB Control Number and Expiration Date 1219-0014; 12/31/16.
Public reporting burden for this form is estimated to average 12 minutes per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. This
collection of information is voluntary. You are not required to respond to this collection of information unless it displays a valid OMB control
number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: to the Mine Safety
and Health Administration, U.S. Department of Labor, Office of Standards Regulations and Variances, 201 12th Street South, Arlington, VA
22202, Paperwork Reduction Project (1219-0014). NOTE: Do not send your completed form to this address.

*
Step 1: Contact Information
I would like to file an anonymous Hazardous Condition Complaint. (Contact information is optional; however, a phone number or e-mail address can help if there are
follow-up questions. Your information will be kept strictly confidential.)
I would like to file a Hazardous Condition Complaint and my contact information is provided below. I understand that my contact information is for use by MSHA only
and will be kept strictly confidential.

First Name:
Last Name:
Contact Phone:
Email Address:

Check the box to the left if you would like to file a formal Hazardous Condition Complaint. To submit a formal hazardous condition
complaint, a valid email address is required. MSHA uses this email address to confirm your intention to "sign" the complaint electronically.

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Mine Safety and Health Administration (MSHA) | 201 12th Street South Suite 401, Arlington, VA 22202-5452
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https://lakegovprod2.msha.gov/HazardousConditionComplaint.aspx[9/26/2016 1:37:34 PM]