Occupational Safety And Health Complaint Form Page 2

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STATE USE ONLY
State of New Jersey
Complaint No.
Date Rec’d
Date Closed
Investigator Code
PUBLIC EMPLOYEES
OCCUPATIONAL SAFETY AND HEALTH
Completed By
[
] Complainant
[
] Department
COMPLAINT
1. Name of Employer
2. Telephone Number
(
)
3. Street Address (Mailing)
4. City, State, Zip Code
5. County
6. Type (Check one)
State Agency
County
Municipality
School Board
Utility Authority
Other (Specify):
7. Hazard Location/Name of Building (Specify building and exact location where alleged
8. Floor and Room Number
violation exists. Use separate form for each building.)
9. Street Address (Site)
10. City, State, Zip Code
11. County
12. Name of Person(s) in Charge
13. Telephone Number
(
)
14. Briefly describe your complaint:
15. Approximate Number of Employees
a.
Are there employees who believe they
b.
Number of employees experiencing
in Area
have health problems related to the
symptoms?
complaint?
Yes
No
16. Type of work done in the area (i.e., clerical, maintenance, firefighter)
17. Materials handled (chemicals, cleaning compounds, etc.)
18a. To your knowledge, has there been a previous inspection related to
b. If Yes, by whom?
the complaint?
Yes
No
c. Date Inspected
d. Outcome of Inspection

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