US Dept of Labor

Occupational Safety & Health AdministrationWe Can Help

OSHA ONLINE WHISTLEBLOWER COMPLAINT FORM

Notice of Whistleblower Complaint

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 30, but READ THIS first. Items noted with an asterisk (*) are required in order to accept your submission.

US Department of Labor
Occupational Safety and Health Administration
Notice of Whistleblower Complaint

OMB # 1218-0236

PART 1 - EMPLOYEE INFORMATION

Required fields denoted by *

1. Name*:

2. Present Address:

3. Telephone Numbers*: (at least one required)

Home:
()
Work:
()Ext
  Cell:
()

4. Email Address:

5. Preferred Method of Contact:

6. Best time to be contacted: (include time zone)

7. Work Site Address at Place of Employment where Alleged Retaliation Occurred

8. Date of Hire at Place of Employment where Alleged Retaliation Occurred:

9. Job Title at Place of Employment where Alleged Retaliation Occurred:

10. Exclusive bargaining (union) representative (if any):

11. The person filing this complaint is:

If you are an authorized representative of the complainant, please complete Part 4 - Identification of Representative.

PART 2 - EMPLOYER INFORMATION

12. Employer Name*:

13. Name and Title of Management Person (for contact purposes only)

Name:

Title:

Phone:

()Ext

14. Name and Title of Supervisor:

Name:

Title:

15. Employer Mailing Address (if different from worksite address in #7):

Street:

16. Employer Phone:

()Ext

17. Employer Fax:

()

18. Employer Email:

19. Type of Business:

PART 3 - ALLEGATION OF DISCRIMINATION/RETALIATION

Please answer the questions below in the space provided. If you need additional space, use the "Additional Comments" section.

20. What management person is responsible for the retaliation you are reporting:

Name:

Position/Title:

21. What are the actions or events that you are reporting to OSHA?* (You may check one or more of the boxes below)








22. When did the employer take these actions against you? Please list all relevant date(s), ex. (mm/dd/yyyy), to the best of your recollection. (If you cannot remember the exact date, please put the approximate date)

23. When did you first learn that the action(s) would be taken against you? Please list all relevant date(s), ex. (mm/dd/yyyy), to the best of your recollection. (If you cannot remember the exact date, please put the approximate date)

24. What reason(s) did the employer give you for each of these actions?

25. Why do you believe the employer took these actions against you? (You may check one or more of the boxes below)






26. For any of the actions you listed in #25, please provide the relevant date(s), ex. (mm/dd/yyyy), you engaged in that activity.

27. Do you believe the employer knew you engaged in the activity described in #25? If so, how do you think they learned of it?

28. Have you filed any previous complaints against this employer with OSHA regarding these or similar retaliatory actions?

If yes, please provide the complaint number and date filed.

Complaint Number:
Date filed:

29. Have you taken any other action(s) to appeal, grieve, or report this matter under any other procedure? If yes, please list the agency/organization(s) with whom you have appealed/grieved/reported this matter, the date filed, the current status of the procedure, and any outcome:

30. How did you first become aware that you could file a complaint with OSHA?

PART 4 - IDENTIFICATION OF REPRESENTATIVE

Complete this part if you are an authorized representative of the complainant. If an investigation is opened, you will be asked to submit a signed Designation of Representative Form that will be sent to you.

If you are filing this complaint on your own behalf, do NOT complete this part.

Name:

Title:

Organization Name:

Union Affiliation:

Address:

Street:

Phone:

()Ext:

Cell:

()

Email:

PART 5 - CERTIFICATION

NOTE: It is unlawful to make any materially false, fictitious, or fraudulent statement to an agency of the United States. Violations can be punished by a fine or by imprisonment of not more than five years, or by both. See 18 U.S.C. 1001(a); 29 U.S.C. 666(g).

Additional Comments

Please provide any additional comments that may be pertinent to your claim:

Warning
This complaint information will be cleared and cannot be recovered.
Are you sure?

OSHA 8-60.1 (Rev.1/13)

Thank You for Visiting Our Website

You are exiting the Department of Labor’s Web server.

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. The Department of Labor also cannot authorize the use of copyrighted materials contained in linked Web sites. Users must request such authorization from the sponsor of the linked Web site. Thank you for visiting our site. Please click the button below to continue.

Close