Notice of Alleged Safety or Health Hazards

U.S. Department of Labor
Occupational Safety & Health Administration
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OSHA 7 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

* 5. Site ZIP Code:

6. Mailing Address
(if different):

7. Management Official:

8. Telephone Number:

9. Type of Business:

* 10. Hazard Description.

Describe briefly the hazards(s) which you believe exist.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):

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 my Employer
My name may be revealed to my Employer

* 15. Complainant Name:

* 16. Complainant Telephone Number:

17. Complainant Mailing Address

Street:

City:

State:

ZIP Code:

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:

Organization Name:

Your Title:

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 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. Persons are not required to respond to the collection of information unless it displays currently valid OMB number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of IRM Policy, Department of Labor, Room N-3101, 200 Constitution Avenue, NW, Washington, DC, 20010; and to the Office of Management and Budget, Paperwork Reduction Project (1218-0064), Wash, D.C. 20503.

DO NOT SEND THE COMPLETED FORM TO EITHER OF THESE OFFICES.

OMB Approval# 1218-0064; Expires: 12-31-2004


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