Instructions for Completing OSHA Safety/Health Complaint Form
1. Complaint Number: Leave blank
2. Employer Name: Company name
3. Site Location (Street, City, State, Zip): Physical address
4. Mailing Address (if different from physical address)
5. Management Official: Name of management person and title
6. Telephone Number: Company telephone number
7. Type of Business: What product is made? What work is being done?
8. Hazard Description: What is the safety and health hazard?
9. Hazard Location: Where in the facility is the hazard located?
10. Has condition been brought to the attention of your employer or a different government agency? (Please check blocks that apply).
11. Please indicate your desire to reveal your name or not to reveal your name to the employer.
12. What is your current status with the company: Employee, former employee, relative of employee, representative (lawyer, doctor, union, etc.)
13. Complainant Name: Your name
14. Telephone Number: A number where you can be reached
15. Address: Your current mailing address
16. Signature: Please sign the complaint form.
17. Date: Please date the form when you sign it.
18. Representative of Employee: Complete this if you are an Attorney or Union Representative.