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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
This condition has been brought to the attention of: (Choose all that apply)
I am a...
Please Indicate Your Desire
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.
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

  • This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.