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To report an emergency, fatality, or imminent life threatening situation please contact our toll free number immediately:
Please fill out sections 1 through 19, but READ THIS FIRST. Items noted with an asterisk (*) are required in order to accept your submission.
Note: In order for OSHA to fully process your complaint, complete and accurate information about the worksite is necessary.
Note: Please select a State first before entering the Establishment City.
Note: Please select a State first and enter a city before selecting a ZIP Code.
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:
12. This condition has been brought to the attention of: (Choose all that apply)
13. I am a(n):* (Required)
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:
17. Complainant Mailing 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:
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 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@dol.gov.
OMB Approval# 1218-0064; Expires: 07-31-2024
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.