Safety & Health Complaint Form

Establishment Name

The type of work being done.

Worksite Address

Worksite Address
Mailing Address is different?

Mailing Address

Mailing Address

Management Information

Management Offical Name

Management Official Name

Management Contact Info

Incident Details

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:

Attachments

Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Other Organizations Contacted

Relationship to Complainant

Confidentiality

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.
Privacy Preference

Certification

Signature

Sign above

Complainant Information

Complainant Name

Complainant Name

Complainant Address

Complaintant Mailing Address

Complainant Contact Information

Authorized Representative Information

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.