Complaint Form (Page 2 of 2) in pdf

NAVAJO OCCUPATIONAL SAFETY & HEALTH ADM INISTRATION

THE DIVISION OF HUM AN RESOURCES

NOTICE OF ALLEGED SAFETY OR HEALTH HAZARDS FORM

Date of Incident:

COMPLAINT NUMBER:

Establishment Name:

Employer’s Name:

Establishment’s

Physical Address:

Mailing Address:

Immediate Supervisor:

Employer’s Telephone:

FAX#:

Nature of Business:

Describe fully the hazards that you believe exist including the number of employees exposed:

Specify each location or work area where the hazards describe above exist:

THIS CONDITION HAS BEEN BROUGHT TO THE ATTENTION OF: (Check all that apply)

☐

Employer

☐

FEDERAL OSHA

☐

Other Government Agency (Specify):

Reporting Person:

Telephone:

Mailing Address:

Relationship to Employer:

☐

Employee

☐

Other (Specify): _____________________________________________

If person filing complaint is an employee representative, What organization does the complainant represent (Provide the

name and local# of the organization and your title, if appropriate):

The identity of the person filing this complaint will be revealed to the employer unless the release of the name will result in

substantial harm to the person filing the complaint please indicate the following:

My name may be revealed

☐

Do not reveal my name to the employer because (Specify): ____________________________________________________

☐

(MARK “X” IN ONE BOX)

Representative of Employees

☐

Former Employee

☐

Federal Safety & Health Committee

☐

Current Employee

☐

_______________________________

Other (Specify):

☐

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.

Print Name:

Telephone:

(

)

Signature:

Date:

Navajo Occupational Safety & Health Administration

PHONE: (928) 871-6742

Physical Address: 2689 Window Rock Blvd., Window Rock, AZ 86515

FAX: (928) 871-6825

Mailing Address: P.O. BOX 1447, Window Rock, AZ 86515

Created by: NOSHA-DT

Complaint Form Page 2

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