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:

Address Line 1
Address Line 2
City
State
Zip Code - -
• Mailing Address (If different)
- - -
Address line 1
Address line 2
City
State
Zip Code - -
Management Offical
First Name
Last Name
Describe briefly the hazard(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
- - -
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.
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.
Address line 2
City
State
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