Proposed Changes to Revised Online Complaint Form

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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:

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 employees and employee representatives 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:

This constitutes my electronic signature.

(If this box is checked, this submission shall be considered as an authorized written signature.)

* 16. Complainant Telephone Number:

17. Complainant Mailing Address
Street:

City:

State:

Select a State

ZIP Code:

* 18. Complainant E-Mail Address: jane.doe@example.com

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 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 DEP.PRA@dol.gov.

OMB Approval# 1218-0064; Expires: 07-31-2024
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

UNITED STATES

DEPARTMENT OF LABOR

Occupational Safety and Health Administration

200 Constitution Ave NW

Washington, DC 20210

 800-321-6742 (OSHA)

TTY

www.OSHA.gov
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