Safety Complaint Form

Welcome to the Notice of Alleged Safety or Health Hazards Online Complaint Form. In order for VOSHA to fully process your complaint, complete and accurate information about the worksite is necessary.

NOTICE:To report an emergency, fatality, or imminent life threatening situation please contact our toll free number immediately:(800) 287-2765. Do not report an emergency using this form or by email.

VOSHA SAFETY COMPLAINT FORM:

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Establishment Name *

Employer Telephone *

Site Physical Address *

Address Line 1

Address 2

Address Line 2

City Name *

City

State *

State

Zip *

Zip Code - -

• Mailing Address (If different)

- - -

Address line 1

Address line 2

Mailing City

City

Mailing State *

State

Mailing Zip

Zip Code - -

Management Offical

First Name *

First Name

Last Name *

Last Name

Type of Business *

Hazard Description *

Describe briefly the hazard(s) which you believe exist. Include the approximate number of employees exposed to or threatened by each hazard.

Hazard Location *

Specify the particular building or worksite where the alleged violation exists

This condition has been brought to the attention of: (Choose all that apply) *

Employer

Government Agency

I am a... *

Employee

Representative of Employees

Other

If "Other" Please Describe

- - -

Please Indicate Your Desire *

Do NOT reveal my name to my Employer

My name may be revealed to my Employer

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.

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

This constitutes my electronic signature. *

This constitutes my electronic signature.

Complainant Name *

While disclosing your name is optional, Your name MUST be submitted for this complaint to be "formal". If you chose not to enter your name, the complaint will be considered an "informal" complaint.

Complainant email address *

Complainant Telephone *

Complainant Mailing Address *

Comp address line 2

Address line 2

Comp City *

City

Comp State *

State

Comp Zip *

Zip Code

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 *

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