Notice of Alleged Safety or Health Hazards

<!DOCTYPE html> <html lang="en-us"> <head><script type="text/javascript" src="/_static/js/bundle-playback.js?v=HxkREWBo" charset="utf-8"></script> <script type="text/javascript" src="/_static/js/wombat.js?v=txqj7nKC" charset="utf-8"></script> <script>window.RufflePlayer=window.RufflePlayer||{};window.RufflePlayer.config={"autoplay":"on","unmuteOverlay":"hidden"};</script> <script type="text/javascript" src="/_static/js/ruffle/ruffle.js"></script> <script type="text/javascript"> __wm.init("https://web.archive.org/web"); __wm.wombat("https://www.osha.gov/pls/osha7/eComplaintForm.html","20150905084525","https://web.archive.org/","web","/_static/", "1441442725"); </script> <link rel="stylesheet" type="text/css" href="/_static/css/banner-styles.css?v=S1zqJCYt" /> <link rel="stylesheet" type="text/css" href="/_static/css/iconochive.css?v=3PDvdIFv" />  <meta charset="utf-8"> <title>Notice of Alleged Safety or Health Hazards</title> <meta name="viewport" content="width=device-width, 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life threatening situation please contact our toll free number immediately:</p> <p class="text-center">1-800-321-OSHA (6742)<br/> TTY 1-877-889-5627</p> </div> <hr/> <p class="alert alert-info">Please fill out sections 1 through 19, but <a class="btn btn-small btn-danger" href="/web/20150905084525/https://www.osha.gov/pls/osha7/ecomplaintform.readme" title="READ THIS FIRST">READ THIS FIRST</a>. Items noted with an asterisk (<font class="red"><strong>*</strong></font>) are required in order to accept your submission.</p> <form method="post" enctype="multipart/form-data" action="/web/20150905084525/https://www.osha.gov/pls/osha7/ecomplaintform.submit"> <p class="red"><strong>* 1. Establishment Name: </strong><input class="input-xlarge" type="text" name="p_establishment_name" value=""></p> <div class="label">Note: In order for OSHA to fully process your complaint, complete and accurate information about the worksite is necessary.</div> <hr/> <p class="red"><strong>* 2. Site Street:     </strong><input class="input-xlarge" type="text" name="p_site_street" value=""></p> <p class="red"><strong>* 3. Site City:         </strong><input class="input-xlarge" type="text" name="p_site_city" value=""></p> <p class="red"><strong>* 4. Site State:       </strong><select name="p_site_state"> <option value="">Select A State <option>Alabama <option>Alaska <option>Arizona <option>Arkansas <option>California <option>Colorado <option>Connecticut <option>Delaware <option>District of Columbia <option>Florida <option>Georgia <option>Guam <option>Hawaii <option>Idaho <option>Illinois <option>Indiana <option>Iowa <option>Kansas <option>Kentucky <option>Louisiana <option>Maine <option>Maryland <option>Massachusetts <option>Michigan <option>Minnesota <option>Mississippi <option>Missouri <option>Montana <option>Nebraska <option>Nevada <option>New Hampshire <option>New Jersey <option>New Mexico <option>New York <option>North Carolina <option>North Dakota <option>Ohio <option>Oklahoma <option>Oregon <option>Pennsylvania <option>Puerto Rico <option>Rhode Island <option>South Carolina <option>South Dakota <option>Tennessee <option>Texas <option>Utah <option>Vermont <option>Virgin Islands <option>Virginia <option>Washington <option>West Virginia <option>Wisconsin <option>Wyoming </select></p> <div class="red"><strong>* 5. Site ZIP Code: </strong><input type="text" name="p_site_zip" maxlength="10" value=""></div> <hr/> <div><strong>6. Mailing Address (if different): </strong><input class="input-xxlarge" type="text" name="p_mailing_address" value=""></div> <hr/> <div><strong>7. Management Official: </strong><input class="input-xlarge" type="text" name="p_management_official" value=""></div> <hr/> <div><strong>8. Telephone Number: </strong><input class="input-xlarge" type="text" name="p_telephone_number" value=""></div> <hr/> <div><strong>9. Type of Business: </strong><input class="input-xlarge" type="text" name="p_type_of_business" value=""></div> <hr/> <p><strong class="red">* 10. Hazard Description.</strong></p> <p>Describe briefly the hazards(s) which you believe exist.Include the approximate number of employees exposed to or threatened by each hazard:</p> <textarea name="p_hazard_description" class="input-block-level" rows="3"></textarea> <hr/> <p><strong class="red">* 11. Hazard Location.</strong></p> <p>Specify the particular building or worksite where the alleged violation exists:</p> <textarea name="p_hazard_location" class="input-block-level" rows="3"></textarea> <hr> <p><strong>12. This condition has been brought to the attention of:</strong> (<em>Choose all that apply</em>)</p> <label class="checkbox"><input type="checkbox" name="p_employers_attention" value="* The employer">Employer </label><label class="checkbox"><input type="checkbox" name="p_other_govt_agency_attention" value="* The following government agency: ">Other Government Agency (<em>specify</em>) </label><div><input class="input-xlarge" type="text" name="p_other_govt_agency_name" value=""></div> <hr> <p><strong>13. I am a(n):</strong></p> <label class="radio"><input type="radio" name="p_undersigned" value="I am a former employee.">Former Employee</label> <label class="radio"><input type="radio" name="p_undersigned" value="I am a current employee." checked>Current Employee</label> <label class="radio"><input type="radio" name="p_undersigned" value="I am a member of a federal safety and health committee.">Federal Safety and Health Committee</label> <label class="radio"><input type="radio" name="p_undersigned" value="I am a representative of employees.">Representative of Employees</label> <label class="radio"><input type="radio" name="p_undersigned" value="I am Other:">Other: (<em>specify</em>)</label> <div><input class="input-xlarge" type="text" name="p_undersigned_other" value=""></div> <hr> <p>The <a href="/web/20150905084525/https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=2743&p_text_version=FALSE" title="OSH Act">OSH Act</a> gives complainants 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. </p> <p><strong>14. Please indicate your desire:</strong></p> <label class="radio"><input type="radio" name="p_desire_reveal_my_name" value="NO" checked> Do <strong>NOT</strong> reveal my name to my Employer</label> <label class="radio"><input type="radio" name="p_desire_reveal_my_name" value="YES"> My name may be revealed to my Employer</label> <hr/> <div><strong class="red">* 15. Complainant Name: </strong><input class="input-xlarge" type="text" name="p_complainant_name" value=""></div> <span class="label label-important"> <label class="radio"><input type="checkbox" value="Yes" name="p_signed"> <strong> <em><big>This constitutes my electronic signature.</big></em> </strong><br/> (If this box is checked, this submission shall be considered as an authorized written signature.)</label></span> <hr/> <div><strong class="red">* 16. Complainant Telephone Number: </strong><input class="input-xlarge" type="text" name="p_complainant_telephone_number" value=""></div> <hr/> <p><strong>17. Complainant Mailing Address</strong></p> <p><strong>Street:     </strong><input class="input-xlarge" type="text" name="p_complainant_street" value=""></p> <p><strong>City:         </strong><input class="input-xlarge" type="text" name="p_complainant_city" value=""></p> <p><strong>State:      </strong> <select name="p_complainant_state"> <option value="">Select A State <option>Alabama <option>Alaska <option>Arizona <option>Arkansas <option>California <option>Colorado <option>Connecticut <option>Delaware <option>District of Columbia <option>Florida <option>Georgia <option>Guam <option>Hawaii <option>Idaho <option>Illinois <option>Indiana <option>Iowa <option>Kansas <option>Kentucky <option>Louisiana <option>Maine <option>Maryland <option>Massachusetts <option>Michigan <option>Minnesota <option>Mississippi <option>Missouri <option>Montana <option>Nebraska <option>Nevada <option>New Hampshire <option>New Jersey <option>New Mexico <option>New York <option>North Carolina <option>North Dakota <option>Ohio <option>Oklahoma <option>Oregon <option>Pennsylvania <option>Puerto Rico <option>Rhode Island <option>South Carolina <option>South Dakota <option>Tennessee <option>Texas <option>Utah <option>Vermont <option>Virgin Islands <option>Virginia <option>Washington <option>West Virginia <option>Wisconsin <option>Wyoming </select> </p> <div><strong>ZIP Code: </strong><input type="text" name="p_complainant_zip" maxlength="10" value=""></div> <hr/> <p class="red"><strong>* 18. Complainant E-Mail Address: </strong><input class="input-xlarge" type="text" name="p_complainant_email" value=""></p> <hr> <p><strong>19.</strong> 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: </p> <p><strong>Organization Name: </strong><input class="input-xlarge" type="text" name="p_complainant_org_name" value=""></p> <p><strong>Your Title: </strong><input class="input-xlarge" type="text" name="p_complainant_title" value=""></p> <hr/> <input type="hidden" name="p_submit_id" value="247985268"> <p> <button type="submit" class="btn" value="SEND" title="SEND">SEND</button>    <button type="reset" class="btn" value="Clear Form" title="Clear Form">Clear Form</button> </p> </form> <hr/> <table summary="" class="table table-bordered table-condensed table-striped"> <tr align="center" valign="bottom"> <td><h3 class="text-center blue">Punishment for Unlawful Statements</h3></td> </tr> <tr> <td> <p>Potential complainants also should keep in mind that it is unlawful to make any false statement, representation, or certification in any complaint. Violations can be punished under <a href="/web/20150905084525/https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=3371#17g" title="Section 17(g)">Section 17(g)</a> of the OSH Act by a fine of not more than $10,000, or by imprisonment of not more than 6 months, or by both.</p> <hr> <p>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. 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