Request For Safety And Health Inspection Of Employing Office Form - Office Of Compliance

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O
C
FFICE OF
OMPLIANCE
O
G
C
FFICE OF THE
ENERAL
OUNSEL
DO NOT WRITE IN THIS SPACE
Request for Safety and Health Inspection of Employing Office
Case No.
VERSION 2011.06.01
Page 1
Date Filed
I am an employee or a representative of an employing office in the Legislative Branch.
I am requesting this inspection because I believe that a safety or health hazard exists in the workplace.
I
wish to
do not wish to remain anonymous.
IF YOU WISH TO REMAIN ANONYMOUS, YOUR NAME WILL NOT BE REVEALED TO OTHERS UNLESS YOU TELL US OTHERWISE.
Description of the hazard. Describe the unsafe acts and/or hazardous conditions and any injuries, illnesses, or “close
calls” caused by these acts or conditions.
INCLUDE DETAILS SUCH AS DATES AND LOCATIONS. ADDITIONAL OR SUPPORTING INFORMATION MAY BE ATTACHED.
Does the hazard described above continue to occur?
Yes
No
I don’t know
If it continues, how often does it occur?
Continually
Daily
Weekly
Monthly
Other frequency
Room LA 200, Adams Building • 110 Second Street, SE • Washington, DC 20540-1999 • t/202.724.9250 • f/202.426.1663 • tdd/202.426.1912

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