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:

Establishment Name

Employer Telephone

Site Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (If different)

Address line 1

Address line 2

City

Mailing State

Mailing Zip

Management Official

First Name

Last Name

Type of Business

Hazard Description

Hazard Location

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.

This constitutes my electronic signature.

Complainant Name

Complainant email address

Complainant Telephone

Complainant Mailing Address

Address line 2

City

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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