Complaint Form

Department of Labor
VOSHA

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:

1-800-287-2765

Please fill out sections 1 through 19.
Items noted with an asterisk (*) are required in order to accept your submission.

* 1. Establishment Name:

NOTE: In order for VOSHA to fully process your complaint, complete and accurate information about the worksite is necessary.

* 2. Site Street Address:
* 3. Site City:
4. State:
* 5. Site Zip Code:
6. Mail Address (if different):
7. Management Official:
8. Telephone Number:
9. Type of Business:
*10. Hazard Description:
Describe briefly the hazard(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 Representative of Employees Other: (specify)
The VOSHA Act gives complainants the right to request that their names not be revealed to their employer. Providing your name and address will only allow VOSHA 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 email address:
* 17. Complainant Telephone Number:
18. Complainant Mailing Address
Street:
City:
State:		If other, specify:
Zip Code:
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:

Vermont Occupational Safety & Health Administration
National Life Building, Drawer 20
Montpelier, VT 05620-3401
1-800-287-2765
email: voshainfo@labor.state.vt.us