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OSHA Online Complaint Form
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
Please fill out sections 1 through 19, but READ
THIS FIRST . Items noted with an asterisk (*)
are required in order to accept your submission.
Note: In order for OSHA to fully process your complaint, complete and accurate information about the worksite is necessary.
3. Site City:
4. Site State: Select A State
Mailing Address (if different):
/
Telephone Number:
Type of Business:
10. Hazard Description.
Describe briefly the hazards(s) which you believe exist and on what date you last observed the hazards. Include the approximate number of employees exposed to or threatened by each hazard:
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)
Former Employee Current Employee
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.
Do NOT reveal my name to my Employer My name may be revealed to my Employer
15. Complainant Name:
This constitutes my electronic signature.
/
16. Complainant Telephone Number:17. Complainant Mailing Address Street:
City:
State: Select A State
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:
Your Title:
SEND Clear Form
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 at [email protected].
,
Department
of
Labor,
Room
N-3119,
200
Constitution
Ave.,
NW,
Washington,
DC;
20210.
OMB Approval# 1218-0064; Expires: 11-30-2020
UNITED STATES DEPARTMENT OF LABOR
Occupational Safety and Health Administration 200 Constitution Ave NW
Washington, DC 20210
800-321-6742 (OSHA) TTY
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Seeman, Laura - OSHA |
File Modified | 0000-00-00 |
File Created | 2024-07-25 |