This report format is provided to assist Federal employees or authorized representatives in registering a report of unsafe or 

unhealthful working conditions with the U.S. Department of Labor. 

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 your 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 your suspicion that a hazard exists (for instance, a recent accident or

physical/health symptoms of employees at your site) include the information in your description. If you need more space than is provided

on the form, continue on any other sheet of paper. 

 

U. S. Department of Labor

Occupational Safety and Health Administration 

Notice of Alleged Safety or Health Hazards 

0BFor the General Public: 

This form is provided for the assistance of any complainant 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 Williams-Steiger Occupational Safety and Health Act, 29 U.S.C. 651, provides as follows: 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 the Secretary or his 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 of 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 the Secretary determines there are reasonable grounds to believe that such violation 

or danger exists, he shall make a special inspection in accordance with the provisions of this section as soon as practicable to 

determine if such violation or danger exists. If the Secretary determines there are no 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 11(c) of the Act provides explicit protection for employees exercising their rights, including making safety and health 

complaints. 

1BFor Federal Employees: 

The Secretary of Labor may conduct unannounced inspections of agency workplaces when deemed necessary if an agency does 

not have occupational safety and health committees established in accordance with Subpart F, 29 CFR 1960; or in response to 

the reports of unsafe or unhealthful working conditions upon request of such agency committees under Sec. 1-3, Executive Order 

12196; or in the case of a report of imminent danger when such a committee has not responded to the report as required in Sec. 1-

201(h). 

2BInstructions: 

After you have completed the form, return it to your local OSHA office, found at https://www.osha.gov. 

NOTE: It is unlawful to make any false statement, representation or certification in any document filed pursuant to the Occupational Safety and 

Health Act of 1970. Violations can be punished by a fine of not more than $10,000. or by imprisonment of not more than six months, or by 

both. (Section 17(g)) 

3BPaperwork Reduction Act Statement: 

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 OMB Control Number. Send comments 

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

Directorate of Enforcement Programs at DEP.PRA@dol.gov. 

OMB Approval# 1218-0064; Expires: 07-31-2024 

Do not send the completed form to this Office. 
 

 

 

 

Do NOT reveal my name to my Employer 

My name may be revealed to the Employer 

Former Employee 

Current Employee 

Representative of Employees 

Federal Safety and Health Committee 

 

U. S. Department of Labor

Occupational Safety and Health Administration 

Notice of Alleged Safety or Health Hazards 

Complaint Number 

Establishment Name 

Site Address 

Site Phone Site Fax 

Mailing Address 

Mail Phone Mail Fax 

Management Official Telephone 

Type of Business 

HAZARD DESCRIPTION/LOCATION. Describe briefly the hazard(s) which you believe exist and on what date you last observed the hazard(s). Include 

the approximate number of employees exposed to or threatened by each hazard. Specify the particular building or worksite where the alleged violation exists. 

Has this condition been brought to 

the attention of:  Employer  Other Government Agency (specify): 

Please Indicate Your Desire: 













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. (Mark "X" in 

ONE box). 



Complainant Name Telephone 

Address (Street, City, State, Zip) 

Email Address 

Signature Date 

If you are an authorized representative of employees affected by this complaint, please state the name of the organization that you 

represent and your title: 

Organization Name: Your Title: 

The OSH Act gives employees and employee representatives the 

right to request that their names not be revealed to their 

employer. Providing your name and address will only allow 

OSHA staff to communicate with you regarding your 

complaint.