Complaint Form
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1FOR OFFICE USE ONLY
Iowa OSHA
1000 East Grand Avenue
Close:
Yes
No
Formal
Non-formal
Des Moines, IA 50319-0209
Diary sheet updated:
Yes
No
Phone: 515-242-5870
Database updated:
Yes
No
Fax: 515-281-7995
Complaint #
Case file #
OSHA@iwd.iowa.gov
CSHO
NAICS
Complaint Form
Transferred:
Yes
No
Instructions
Complete this form if you wish to complain about a workplace safety or health issue. If you need more
space you may continue on another page.
It is illegal for an employer to retaliate against an employee who files an OSHA complaint.
It is illegal to make a false statement on this complaint form.
Send this form and any attachments by mail, fax or email (see above).
Employer name
Type of business
Site address
Management official
City
State
Zip
Mailing address
Same as site address
City
State
Zip
Phone
Fax
Email
Describe danger to employee
Location
# exposed
Please indicate your preference
Do NOT reveal my name
My name may be revealed
This condition has been brought to the attention of
Employer
Other Gov agency (specify)
Current employee
Former employee
Employee representative
Which best
desribes you
Other (Specify)
Your name
Address
City
State
Zip
Email
Phone
Complete this section if you are an authorized representative of the affected employees
Organization name
Title
I have correctly described dangerous violations of OSHA standards
Signature
Date
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Parent category: Business