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Michigan Occupational Safety and Health Administration
Safety and Health Hazards Complaint Form
It is unlawful to make any false statement, representation or certification in any document filed pursuant to the Michigan Occupational Safety and Health Act of 1974, as amended. Violators can be punished by a fine of not more than $10,000, or by imprisonment of not more than six months, or by both (Section 35(7)).
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GENERAL INDUSTRY SAFETY and HEALTH CONSTRUCTION SAFETY and HEALTH
Establishment Name:

Site Street 1:

Site Street 2:

City:
State:
MI
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:
This constitutes my electronic signature. (If this box is checked, this submission shall be
considered as an authorized written signature.)
Complainant Telephone:
- -  
If you wish to receive a copy of the results of this complaint, please provide your mailing address below.
COMPLAINANT ADDRESS
Street 1:
Street 2:
City:
State:
Zip Code:
  Email:
(Required to process the complaint online)
 
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.
  
Type the characters you see in the picture above.
 
 
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