Occupational Safety And Health Complaint Form Page 3
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3STATE USE ONLY
State of New Jersey
Complaint No.
PUBLIC EMPLOYEES
OCCUPATIONAL SAFETY AND HEALTH
COMPLAINT
(Continued)
19. To your knowledge, has this complaint been the subject of any union/management grievance or have you (or anyone you know) otherwise called it to
the attention of, or discussed it with, the employer or any representative thereof?
Yes
No
If Yes, give the results thereof, including any efforts by management to correct the violation.
20. Name of Union
21. Local Number
22. Name of Employee Representative
23. Telephone Number
(
)
24. Title
THE INFORMATION BELOW WILL REMAIN CONFIDENTIAL UPON REQUEST
25. Please indicate your desire:
DO NOT REVEAL MY NAME TO THE EMPLOYER.
MY NAME MAY BE REVEALED TO THE EMPLOYER.
OR
I WANT TO BE PRESENT WHEN THE INSPECTION IS
CONDUCTED.
26. The complainant, whose signature appears below (check one):
Employee
Representative of Employees
Employer
Other (Specify):
28. Signature (Required)
27. Name of Complainant (Print or Type)
29. Date
30. Street Address
31. City, State, Zip
32. County
33. Telephone Number
34. Best Time to Contact
(
)
IF YOU ARE AN AUTHORIZED REPRESENTATIVE OF EMPLOYEES
AFFECTED BY THIS COMPLAINT, COMPLETE THE FOLLOWING:
35. Name of Organization
36. Your Organization Title
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