DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. Download a PDF complaint form and fax or mail it to your local OSHA Regional or Area Office; Call the violation in to your local OSHA office or 1-800-321-OSHA; Keep in mind: complaints signed and submitted to local OSHA offices are more likely to result in OSHA inspections. Select A State PRIVACY ACT STATEMENT North Carolina Tennessee Ohio West Virginia If you need more space you may continue on another page. Mississippi Oklahoma Washington, DC 20210 Download the OSHA complaint form, Complete the complaint form or letter, and then fax, mail, or email it back to your local OSHA office. To be successful, IOSHA will improve workplace safety and health for all Indiana workers by reducing hazards and exposures in the workplace environment that result in occupational injuries, illnesses, and fatalities. Name . Indiana Nebraska It is illegal to make a false statement on this complaint form. �hWpPz0h(���C�t��p}. Division of Labor Quick Link Resources. h�b```�eU~�g`��0pl8�a���� �B1�2H7W���u���5�"| The advanced tools of the editor will guide you through the editable PDF template. The Department of Labor does not endorse, takes no responsibility for, and exercises no control over the linked organization or its views, or contents, nor does it vouch for the accuracy or accessibility of the information contained on the destination server. Complete it and then fax or mail it back to the SC OSHA Office. Fax, mail, or email either a letter describing your complaint or a printed copy of your completed Online Whistleblower Complaint Form to your local OSHA office. Kentucky North Dakota After you submit this form to OSHA, an OSHA representative will contact you. Alabama ��������r Discrimination. Mississippi TTY h�bbd``b`�$�A�2�`�bi 6i �qH�7�X .�9�e"�A�7� ����L��@#n�?��/� � Colorado Arizona Site Location (Street, City, State, Zip) 4. Massachusetts Providing your name and address, will only allow OSHA staff to communicate with you regarding your complaint. Online - Use the Online Whistleblower Complaint Form to submit your complaint to OSHA. Wyoming. Complaint Form . Utah The OSH Act gives complainants the right to request that their names not be revealed to their employer. Wisconsin Users must request such authorization from the sponsor of the linked Web site. New Mexico Georgia Do Not Report an Emergency Using this Form or Email! Under the occupational safety and health act (OSHA), all employees have the right to report any form or safety related violations that could expose them to immediate danger. osha.gov The Indiana Occupational Safety and Health Administration (IOSHA) is dedicated to ensuring Hoosier workplace safety and health. Describe briefly the hazards(s) which you believe exist.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. � `g`��D: �Q The Occupational Safety and Health Act of 1972, specifically T.C.A. Louisiana Download the OSHA complaint form and instructions (or request a copy from the SC OSHA Office).. 8/31/16) For the Illinois Public Sector This form is provided for the assistance of any complainant and is not intended to constitutes the exclusive means by which a compliant may be registered with the Illinois Department of Labor- Illinois OSHA. Thank You for Visiting Our Website You are exiting the Department of Labor's Web server. OSHA issues final rule on Crane Operator Certification; ... You have the right to file a complaint and request an inspection if you believe a safety and health hazard exists. Online Penalty Payment. Kansas Download a PDF complaint form and fax or mail it to your local OSHA Regional or Area Office Call the violation in to your local OSHA office or 1-800-321-OSHA Keep in mind: complaints signed and submitted to local OSHA offices are more likely to result in OSHA inspections. American Samoa Washington DC (District of Columbia) Thank you for visiting our site. Missouri Idaho Section 50-3-304(a), provides as follows: “(1) Any Please make sure that your correspondence includes your name, mailing address, email address, and telephone or … * 4. All the questions on the form are listed below, with explanatory notes. To report an emergency, fatality, or imminent life threatening situation please contact our toll free number immediately: 1-800-321-OSHA (6742) Guam Illinois New Jersey Items noted with an asterisk (*) are required in order to accept your submission. CT OSHA-7 (Rev. ���|(�3���*�m�1�X��N�R,��%R��JHH���!�zH3�K����0u�;_���v�z�yMF}�q����9���I�ܮ��L�?�cM��g�i� Management Official 6. Wyoming. 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. Texas Employer Name 3.    South Dakota Minnesota Please provide the following information and sign and date the form. If you want to file a written complaint, you can use the OSHA-7 form or you can write a letter that answers all of the questions that are on the form. Secure, fast and easy. 200 Constitution Ave NW 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 . Wisconsin Colorado The Department of Labor also cannot authorize the use of copyrighted materials contained in linked Web sites. South Dakota 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: SEND Nebraska www.OSHA.gov, Occupational Safety and Health Administration Louisiana 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. After you have completed the form, you may submit it to your local OSHA office by mail, fax, or hand-delivery. For additional information on indoor air quality and filing complaints with OSHA, visit these helpful links: “How to File a Complaint with OSHA” osha.gov “OSHA: We Can Help”- information about the OSHAct of 1970 and Worker Rights. South Carolina TTY 1-877-889-5627. Delaware California A: You can file a complaint with IOSHA by submitting the electronic complaint form, or by mail, email, fax or telephone. ��6מ��|�pk���N�4��f�I�{[�ё�Ub"^-�n�B]�w�,� 18����٨e�)���6^C�ұo����ފ that helps clarify the complaint. North Dakota Describe each hazard you think exists in as much detail as you can. Michigan Florida Read More. 199 0 obj <>/Filter/FlateDecode/ID[<9641DB4502621B4C97EF61C2108B7887><485421C4CF113940B8FD54D2BB234B03>]/Index[184 24]/Info 183 0 R/Length 79/Prev 51972/Root 185 0 R/Size 208/Type/XRef/W[1 2 1]>>stream Minnesota Section 6309 of the California Labor Code provides that a complaint … Web Complaint (11/00) 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 lodged with Cal/OSHA. To make a complaint by mail, send complaint to: Indiana Department of Labor – IOSHA Attention: Complaint Duty Officer Arkansas Michigan c. The Cal/OSHA District Office shall refer any item(s) that fall outside the jurisdiction of Cal/OSHA to any and all appropriate agencies with jurisdiction over the complaint item(s) (see P&P C-90). Connecticut This condition has been brought to the attention of: (Choose all that apply). Please click the button below to continue. indicates required field. Utah Osha Complaint Form. Kentucky Maryland Virginia You may contact Eddie Runyon, Discrimination Investigator, at (502) 385-0716 for help with a discrimination claim. Occupational Safety and Health Administration, Severe Storm and Flood Recovery Assistance. Site Address Required. Sec 8(f)(1) of the Williams-Steiger Occupational Safety and Health Act, 29 … Texas Informal Complaint An informal complaint can be made anonymously by anyone and does not require a signature.Informal complaints result in IOSHA contacting the company to investigate alleged hazards. 0 Rhode Island Puerto Rico Complaint Number Î 2. On November 7, we rectified citation 1 (improper use of fume hood) by replacing the equipment (see enclosed receipt and photo)." OSHA has a list of priority complaints that typically result in … 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. Written complaints that are signed by a worker or representative and submitted to the SC OSHA Office are more likely to result in onsite OSHA … Vermont Washington (State) North Carolina Missouri New Hampshire Select A State Pennsylvania Pennsylvania Oregon Filing an OSHA Complaint – Tips for Completing the OSHA-7 Form INSTRUCTIONS Provided on the Form: Open the form and complete the front page as accurately and completely as possible. IL OSHA Complaint Form (Rev. Note: In order for OSHA to fully process your complaint, complete and accurate information about the worksite is necessary. 19. Massachusetts American Samoa Alabama New York d. The Cal/OSHA District office shall complete a Cal/OSHA 7 form for all complaint … Complaints received online from employees located in States with OSHA-approved State Plans will be forwarded to the appropriate State Plan for response. Arkansas This Instruction implements the OSHA Whistleblower Investigations Manual, and supersedes the April 21, 2015 Instruction . 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, Department of Labor, Room N-3119, 200 Constitution Ave., NW, Washington, DC; 20210. OSHA Online Complaint Form Notice of Alleged Safety or Health Hazards. Clear Form. IOSHA Home. Enter your official identification and contact details. Fill out samples electronically via PC, mobile and tablet Osha 7. Arizona It is illegal for an employer to retaliate against an employee who files an Iowa OSHA complaint. Rhode Island There will be a convenience fee added to credit card payments. h��Vmk�0�+��1�%Y�m(�4[XGWF����njC��eۿ��YR��Y�B�p�ro�����q&�`"�E2�4�1JPF��k&R��ݚ�F��Y�) 3�Ww''�p3+�� Γh�?~.���a���cѺ1���|�a����9;[��h����6X����|U.����b�.���j�ʫ���WEDp�����\��.��"�\׫|I���yt���r6��˂�h��,����cA��l]>6�:��3(���„82��������j]�հڔ����7�h�װY��u4y�o��i�TPO�1(��,6�I��)Rs�1f�4�J TTY 207 0 obj <>stream Oklahoma You can file a complaint by filling out the online complaint form or by contacting our field office closest to worksite. Indiana CNMI Saipan Accordingly, it must decide whether the complaint merits an on-site inspection, or whether the agency will send out a Notice of Alleged Hazard(s) (also known as a “Phone and Fax Complaint”) to the employer. Georgia State:       Site Fax. California You may pay your penalty online using a credit card or electronic check. Contact 1-800-321-OSHA (6742) or visit www.osha.gov to locate a local OSHA office. Hawaii South Carolina Nevada This manual outlines procedures, and other information relative to the handling of retaliation complaints under the various whistleblower statutes delegated to OSHA and may be used as … Illinois 800-321-6742 (OSHA) Guam Iowa Names of Complainants Must Be Kept Confidential: The name of any person who submits a complaint to Cal/OSHA must be kept confidential by law, unless the person requests otherwise. 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 Tennessee Department of Labor and Workforce Development. Site Phone Required. 11/25/2020: Updated Guidance for Business Operations During Nevada’s “Statewide Pause” Effective November 24, 2020. 11/2/2020: Nevada OSHA Enforcement Process During COVID-19 Pandemic. endstream endobj startxref Virgin Islands Please fill out sections 1 through 19, but READ THIS FIRST. Occupational Safety and Health Administration EMERGENCY NOTICE . You may submit the form to our offices via regular mail or fax. FORM OR IN YOUR INITIAL COMPLAINT FILING. Hawaii Nevada OSHA Closed Due to Covid-19. Complainant Information . Oregon Washington (State) 800-321-6742 (OSHA) Connecticut Alaska Maine %%EOF By knowing how to respond to these complaints, one can expect that his or her business stays and meets every single one of the safety needs of the employees. New Jersey Save, share or print forms in seconds. Kansas Failure to complete this form in its entirety may result in your complaint not being processed. copy of the file, including the complaint that I filed with Cal-OSHA against the employer named above. endstream endobj 185 0 obj <>/Metadata 5 0 R/PageLayout/OneColumn/Pages 182 0 R/StructTreeRoot 9 0 R/Type/Catalog>> endobj 186 0 obj <>/Font<>>>/Rotate 0/StructParents 0/Type/Page>> endobj 187 0 obj <>stream www.OSHA.gov. The Department of Labor does not endorse, takes no responsibility for, and exercises no control over the linked organization or its views, or contents, nor does it vouch for the accuracy or accessibility of the information contained on the destination server. Montana For more information on filing a complaint with IOSHA, or to view the electronic complaint form, click here. Washington, DC 20210 Site State:        By my signature I authorize a Cal-OSHA representative to discuss my complaint and the file detailing the correspondence and investigation into my complaint with the Division of Labor Standards Enforcement. OSH Complaint Form. There is an OSHA form for filing a complaint, but OSHA does not require that you use it. Maine CNMI Saipan 01/06) Connecticut Department of Labor Division of Occupational Safety and Health Optional Complaint Number Notice of Alleged Safety or Health Hazards 1. Important Links. West Virginia Mailing address (if different) (Street, City, State, Zip) 5. Right to File a Complaint: The California Occupational Safety and Health Act of 1973 gives workers the right to file a complaint about workplace safety and health hazards. Florida %PDF-1.5 %���� Idaho Download the OSHA complaint form, Telephone - Call Your Local OSHA Office or 800-321-6742 (OSHA) OSHA staff can discuss your complaint with you and respond to any questions you may have. This introductory video shows you how Oregon OSHA's complaint process works. Puerto Rico New York Discrimination Form [PDF, 613KB] OSH Regulations Employees or their representatives may also choose to send a signed letter that contains the same information in lieu of this form. Iowa Do Not Report an Emergency Using this Form or Email! To file a complaint about a workplace safety or health issue, send this completed form and any attachment to the address above. Try now! 200 Constitution Ave NW Tennessee Virgin Islands Delaware Alaska Over the course of the next two days, we investigated citations 1-3 and established corrective actions. The way to fill out the Osha 7 form online: To start the blank, use the Fill & Sign Online button or tick the preview image of the document. Amusement Rides; Asbestos Abatement; Athletic; Bidder Preference; Boilers & Pressure Vessels Vermont Ohio Establishment Name Required. Notice of Alleged Safety or Health Hazards Illinois OSHA 184 0 obj <> endobj Washington DC (District of Columbia) For example, you might say, "On November 5, I received OSHA complaint number 2845. Potential complainants also should keep in mind that it is unlawful to make any false statement, representation, or certification in any complaint. Maryland Nevada New Mexico Virginia New Hampshire Illinois OSHA Safety and Health Complaint Form Notice of Alleged Safety or Health Hazards Form For the Illinois Public Sector. They recommend contacting your local OSHA office right away to file this complaint. Montana OMB Approval# 1218-0064; Expires: 11-30-2020. 6742 ) or visit www.osha.gov to locate a local OSHA office by mail,,. Or mail it back to the SC OSHA office OSHA staff to communicate with you your. 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