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OSHA Online Complaint Form
Notice of Alleged Safety or Health Hazards
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.

* 1. Establishment
Name:

Note: In order for OSHA to fully process your complaint, complete and accurate information about the worksite is necessary.

* 2. Site Street:

* 3. Site City:

* 4. Site State:
Select a State
* 5. Site ZIP Code:

6. Mailing Address (if
different):

7. Management
Official:

8. Telephone Number:

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9. 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:

* 11. Hazard Location.
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 )

* 13. I am a(n):
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.

14. Please indicate
your desire:
Do NOT reveal my name to the Employer
My name may be revealed to the Employer

* 15. Complainant
Name:

This constitutes my electronic signature.

(If this box is checked, this submission shall be considered as an authorized written signature.)
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* 16. Complainant
Telephone Number:

17. Complainant
Mailing Address
Street:

City:

State:
Select a State
ZIP Code:

* 18. Complainant
E-Mail Address:
[email protected]

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:

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
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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.

Paperwork Reduction Act Statement
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].

OMB Approval# 1218-0064; Expires: 08-31-2024
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

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For the General Public
This form is provided for the assistance of any complainant and is not intended to constitute the exclusive means by which a complaint may be
registered with the U.S. Department of Labor
Sec 8(f)(1) of the Williams-Steiger Occupational Safety and Health Act, 29 U.S.C. 657, provides as follows: Any employees or representatives of employees who
believe that a violation of a safety or health standard exists that threatens physical harm, or that an imminent danger exists, may request an inspection by giving
notice to the Secretary or his authorized representative of such violation or danger. Any such notice shall be reduced to writing, shall set forth with reasonable
particularity the grounds for the notice, and shall be signed by the employee or representative of employees, and a copy shall be provided the employer or his
agent no later than at the time of inspection, except that, upon request of the person giving such notice, his name and the names of individual employees referred
to therein shall not appear in such copy or on any record published, released, or made available pursuant to subsection (g) of this section. If upon receipt of such
notification the Secretary determines there are reasonable grounds to believe that such violation or danger exists, he shall make a special inspection in accordance
with the provisions of this section as soon as practicable to determine if such violation or danger exists. If the Secretary determines there are no reasonable
grounds to believe that a violation or danger exists, he shall notify the employees or representative of the employees in writing of such determination.
NOTE: Section 11(c) of the Act provides explicit protection for employees exercising their rights, including making safety and health complaints.

For Federal Employees
This report format is provided to assist Federal employees or authorized representatives in registering a report of unsafe or unhealthful working conditions with the
U.S. Department of Labor.
The Secretary of Labor may conduct unannounced inspections of agency workplaces when deemed necessary if an agency does not have occupational safety and
health committees established in accordance with Subpart F, 29 CFR 1960; or in response to the reports of unsafe or unhealthful working conditions upon request
of such agency committees under Sec. 1-3, Executive Order 12196; or in the case of a report of imminent danger when such a committee has not responded to
the report as required in Sec. 1-201(h).

Instructions
Fill in the form as accurately and completely as possible. Describe each hazard you think exists in as much detail as you can. If the hazards described in your
complaint are not all in the same area, please identify where each hazard can be found at the worksite. If there is any particular evidence that supports your
suspicion that a hazard exists (for instance, a recent accident or physical symptoms of employees at your site) include the information in your description.

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.

Paperwork Reduction Act Statement
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].

OMB Approval# 1218-0064; Expires: 08-31-2024
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

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