OSHA-7 OSHA Form 7 Traditional Chinese

English	Traditional Chinese
OSHA Online Complaint Form	OSHA線上舉報表
Notice of Alleged Safety or Health Hazards	安全或健康危害通知
EMERGENCY NOTICE	緊急通知
Do Not Report an Emergency Using this Form or Email!	如有緊急情況，請勿使用本表格或電子郵件舉報！
To report an emergency, fatality, or imminent life threatening situation please contact our toll free number immediately:	如需報告緊急事件、死亡情況或即將發生的危害生命安全的情況，請立即撥打我們的免費電話：
1-800-321-OSHA (6742)	1-800-321-OSHA (6742)
TTY 1-877-889-5627	TTY 1-877-889-5627
Please fill out sections 1 through 19, but READ THIS FIRST. Items noted with an asterisk (*) are required in order to accept your submission.	請先閱讀此處，隨後填寫1到19部分。帶星號（*）的內容為必填項，否則將無法提交表格。
*1. Establishment Name	*1.單位名稱
Note: In order for OSHA to fully process your complaint, complete and accurate information about the worksite is necessary.	注：為便於OSHA（職業安全與健康管理局）處理您的舉報，完整、準確的工作場所資訊非常重要。
*2. Site Street:	*2.場所街道：
*3. Site City:	*3.場所城市：
*4. Site State:	*4.場所所在州：
*5. Site Zip Code:	*5.場所郵編：
6. Mailing Address (if different):	6.郵寄位址（若不同）：
7. Management Official:	7.管理官員：
8. Telephone Number:	8.電話號碼：
9. Type of Business:	9.業務類型：
*10. Hazard Description.	*10.危害描述。
Describe briefly the hazards(s) which you believe exist. Include the approximate number of employees exposed to or threatened by each hazard:	簡單描述你認為存在的危害。注明每種危害所影響或威脅的雇員的大致數量：
*11. Hazard Location.	*11.危害位置。
Specify the particular building or worksite where the alleged violation exists:	注明違規行為所在的具體建築或工作場所位置：
*12. This condition has been brought to the attention of: (Choose all that apply) □ Employer □ Other Government Agency (specify)	*12.這種情況已得到以下各方的注意：（選擇適用的內容） □ 雇主 □ 其他政府機構（注明）
13. I am a(n): □ Former Employee □ Current Employee □ Federal Safety and Health Committee □ Representative of Employees □ Other: (specify)	13.我是： □ 前任雇員 □ 現任雇員 □ 聯邦安全與健康委員會 □ 雇員代表 □ 其他。（注明）
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.	《工作安全和健康法》規定，舉報人有權利要求不向雇主透露其姓名。提供您的姓名和地址後，OHSA員工不會因舉報事件以外的原因聯繫您。
14. Please Indicate Your Desire: Do NOT reveal my name to my Employer My name may be revealed to the Employer	14.您是否希望透露自己的姓名： 不要向我的雇主透露我的姓名 可以向雇主透露我的姓名
*15. Complainant Name:	*15.舉報人姓名：
This constitutes my electronic signature. (If this box is checked, this submission shall be considered as an authorized written signature.)	這是我的電子簽名。 （如勾選此框，將視為檔已經過授權書面簽名。）
*16. Complainant Telephone Number:	*16.舉報人電話號碼：
17. Complainant Mailing Address Street: City: Sate: ZIP Code:	17.舉報人郵寄地址 街道： 城市： 州： 郵編：
*18. Complainant E-Mail Address:	*18.舉報人郵寄地址：
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:	19.如果你作為雇員的授權代表提出該舉報，請注明你所代表的組織的名稱以及你的職位： 組織名稱： 你的職位
SEND	發送
Clear Form	清除表格
Punishment for Unlawful Statements	違法聲明的處罰
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.	舉報人應謹記，在任何舉報中提供虛假的聲明、陳述或證明均屬違法行為。根據《工作安全和健康法》第17(g)部分規定，違者可處以10,000美元以下罰款或六個月以下監禁，或同時處以罰款和監禁。
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.	公眾填寫此資訊收集表的時間預計為每份15到25分鐘，平均時間為17分鐘，包括查看說明、查詢現有資料、收集和維護所需資料、填寫並檢查表格資訊所需的時間。機構不得開展或發起資訊收集活動。除非資訊收集表具有有效的OMB控制編號，否則公眾沒有對其作出回應的義務。有關預計填寫時間及該資訊收集表的任何其他意見，包括如何縮短填寫時間的建議等，請寄往勞工部實施方案理事會（Directorate of Enforcement Programs, Department of Labor, Room N-3119, 200 Constitution Ave., NW, Washington, DC; 20210）。
OMB Approval# 1218-0064; Expires: 08-31-2017	OMB批准號1218-0064；到期日：08-31-2017
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.	請勿將完成填寫的表格寄到該辦公室。