Safety Health Hazards

It is unlawful to make any false statement, representation or certification in any document filed pursuant to the Michigan Occupational Safety and Health Act of 1974, as amended. Violators 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 35(7)).

I have read the statement above and agree that the information I am submitting on this complaint is truthful and accurate to the best of my knowledge.

* = Required Fields

Complainant Information

Please indicate your current employment status

Current Employee

Representative of Employees

A representative of the certified or recognized bargaining agent, or, if none, an employee member of a safety and health committee who has been chosen by the employees (employee committee members or employees at large) as their MIOSHA representative.

Former Employee (Date Last Worked mm/dd/yyyy):

Other

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 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.

Complainant First Name

Complainant Last Name

This constitutes my electronic signature. (If this box is checked, this submission shall be considered as an authorized written signature.)

Complaints with an electronic signature of the employee or employee representative are more likely to result in an onsite inspection. Complaints without a signature are more likely to be addressed by MIOSHA calling or faxing the employer a letter asking for a response to the complaint allegations.

Complainant Phone

- -

COMPLAINANT ADDRESS

Please indicate how you would like the results of your complaint to be sent to you.

Email me at the address below

Mail the information to me at the address below

Street 1

Street 2

City

State

Zip Code

Confirm Email

Please indicate whether or not you want your name revealed

Do NOT reveal my name to the employer

I want my name revealed to the employer

Establishment Information

GENERAL INDUSTRY SAFETY and HEALTH

CONSTRUCTION SAFETY and HEALTH

Establishment Name

WORKSITE ADDRESS

Site Street 1

Site Street 2

City

State

Zip Code

Site Phone

- -

Site Fax

- -

EMPLOYER MAILING ADDRESS

Employer Mailing Address is different from Worksite Address.

Street 1

Street 2

City

State

Zip Code

Mail Phone

- -

Mail Fax

- -

Management Official

Phone

- -

Type of Business

HAZARD DESCRIPTION/LOCATION. Describe briefly the hazards you believe exist. Include the approximate number of employees exposed to or threatened by each hazard. Specify the particular building or work site where the alleged violation exists.

Has this been brought to the attention of:

Employer

Other government agency (specify)

LEO is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

* Spam blocker . Add Five and Two together and input the total In order to help reduce spam, false/automatic form submissions etc. and at the same time maintain accessibility and usability, the State of Michigan is implementing a simple form of 'human checking'. This simply involves entering the sum of two numbers in an additional form field.

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Safety and Health Hazards Complaint Form

Complainant Information

COMPLAINANT ADDRESS

Establishment Information

WORKSITE ADDRESS

EMPLOYER MAILING ADDRESS