Complaint Form printable pdf download

NAVAJO OCCUPATIONAL SAFETY & HEALTH ADM INISTRATION

THE DIVISION OF HUM AN RESOURCES

NOTICE OF ALLEGED SAFETY OR HEALTH HAZARDS FORM

For the General Public:

This form is provided for the assistance of any complaint and is not intended to constitute the exclusive means by which a

complaint may be registered with the U.S. Department of Labor.

Sec 8 (f)(1) of the William-Steiger Occupational Safety & Health Act, 29 U.S.C. 651, provides as follow: Any Employees or

representative of employees who believe that a violation of a safety or health standard exists that threatens physical harm, or

that an imminent danger exists, may request an inspection by giving notice to Navajo OSHA or his/her authorized

representative of such violation or danger. Any such notice shall be reduced to writing, shall set forth with reasonable

particularity the grounds for the notice, and shall be signed by the employee or representative or employees, and a copy shall

be provided the employer or his agent no later than at the time of inspection, except that, upon request of the person giving

such notice, his name and the names of individual employees referred to therein shall not appear in such copy or on any

record published, released, or made available pursuant to subsection (g) of this section. If upon receipt of such notification

Navajo OSHA determines there are reasonable grounds to believe that a violation or danger exists, he shall notify the

employees or representative of the employees in writing of such determination.

NOTE: Section 1432(B) of the Navajo OSH Act of 2000 provides explicit protection for employees exercising their rights,

including making safety and health complaints.

For Navajo Nation & Other Navajo Entity Employees:

This report format is provided to assist Employees on the Navajo Nation, Other Navajo Entities, and Businesses or

authorized representatives in registering a report of unsafe or unhealthful working conditions with the Navajo Occupational

Safety & Health Administration.

The Navajo OSHA may conduct unannounced inspection of agency workplaces when deemed necessary if an agency does

not have Safety & Health Committees established in accordance with Navajo OSH Act of 2000; or in response to the reports

of unsafe or unhealthful working conditions upon request of such agency committees under Sec.

1401,1402,1403,1411,1421,1422, 13 N.N.C. Chapter 55, Navajo Nation Safety Committee, Sections 4701-4705 in its

entirety.

INSTRUCTIONS:

Open the form and complete the front page as accurately and completely as possible. Describe each hazard

you think exists in as much detail as you can. If the hazards described in you complaint are not all in the same

area, please identify where each hazard can be found at the worksite. If there is any particular evidence that

supports our suspicion that a hazard exists (for instance, a recent accident or physical symptoms of employees

at your site) including the information in your description. If you need more space than is provided on the form

continue on a separate sheet of paper.

After you have completed the form, return it to Navajo OSHA Office.

NOTE:

It is unlawful to make any false statement(s), representation or certification in any document, application, record,

report, plan or other document filed or required to be maintained pursuant to the Occupational Safety & Health Act

of 2000. Violations can be punished by a fine of not more than five thousand dollars ($5000) for each violation or

by imprisonment for not more than six months, or both. Section 1481(H)

Public reporting burden for this voluntary collection of information is estimated to vary from 15 to 25 minutes per

response with an average of 17 minutes per response, including the time for reviewing instructions, searching

existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection

of information. An Agency may not conduct or sponsor, and persons are not required to respond to the

collection of information unless it displays a valid Control Number. Send comment regarding this burden

estimate or any other aspect of this collection of information, including suggestions for reducing this burden to

the Programs & Projects Specialist of Navajo OSHA (2689 Window Rock Blvd, Window Rock, AZ 86515) and

Division Director of Human Resources.

Expires 08/24/18

Send completed form to this Office.

Created by: NOSHA-DT

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