Safety and Health Hazards Complaint Form

Department of Licensing and Regulatory Affairs

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GENERAL INDUSTRY SAFETY and HEALTH

CONSTRUCTION SAFETY and HEALTH

Establishment Name:

Site Street 1:

Site Street 2:

City:

State:

Zip Code:

Site Phone:

- -

Site Fax:

- -

MAILING ADDRESS (If different from site address)

Street 1:

Street 2:

City:

State:

Zip Code:

Mail Phone:

- -

Mail Fax:

- -

Management Official:

Telephone:

- -

Type of Business:

HAZARD DESCRIPTION/LOCATION. Describe briefly the hazards you believe exist. Include the approximate number of employees exposed to or threatened by each hazard. Specify the particular building or work site where the alleged violation exists.

Has this been brought to the attention of:		Employer?
		Other government agency (specify)?

Please indicate whether or not you want your name revealed

Do NOT reveal my name to the employer
I want my name revealed to the employer

Please indicate your current employment status

Current Employee

Representative of Employees

Federal Safety and Health Committee

Other (specify)

Former Employee (Date Last Worked)

Month:

Day:

Year:

The undersigned believes that a violation of an occupational safety or health standard exists which is a job safety or health hazard at the establishment named on this form.

Complainant Name:

Complainant Telephone:

- -

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Must include address or email in order to process the complaint

COMPLAINANT ADDRESS

Street 1:

Street 2:

City:

State:

Zip Code:

Email:

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:

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.


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