Osha Complaint Information Form printable pdf download

Cal/OSHA Complaint Information

When filing a Cal/OSHA (agency) complaint on any facility, there is the pre-

sumption that the Union has attempted to bring remedy at least once or twice

prior to filing a complaint with the agency.

SEIU Local 121RN is unique in that we have a Health and Safety Director who

can file these complaints on behalf of the members and the representatives and track their progress.

In order to bring a complaint forward, the agency is seeking very specific information to open the file against the fa-

cility. The following is a list of items we look to provide, which a representative should be able to provide.

Facility Name______________________________________________________________________________

Facility Address____________________________________________________________________________

Facility Phone_______________________________Facility Fax______________________________________

Type of business_____________________________

Name and job title of management official in charge at the worksite__________________________________

_________________________________________________________________________________________

Name, address and telephone number of the complainant__________________________________________

_________________________________________________________________________________________

Detailed description of the hazard, and its location in the worksite

_________________________________________________________________________________________

Identity of any employees who have been injured as a result of the complaint conditions

_________________________________________________________________________________________

Nature of the work performed in the area of the workplace which is the subject of the complain

_________________________________________________________________________________________

Type and condition of any equipment or machinery in use in the subject workplace and any materials, chemi-

cals, processes or operations involved in the complaint conditions

_________________________________________________________________________________________

How often the work task which is associated with the complaint conditions is performed and for how long at

any one time

_________________________________________________________________________________________

____________________________________________________________________

Over

Osha Complaint Information Form