Labor Commission of Utah

Electronic (on-line) Complaint Form
for Reporting Alleged Safety/Health Hazards

This form is provided for the assistance of any Complaint and is not intended to constitute the exclusive means by which a complaint may be registered with the Utah Occupational Safety and Health Division.

34A6301(6)(a)(i) Any employee or representative of employees who believes that a violation of an adopted safety or health standard exists that threatens physical harm, or that an imminent danger exists, may request an inspection by giving notice to the division's authorized representative of the violation or danger. The notice shall be in writing, setting forth with reasonable particularity the grounds for notice, and signed by the employee or representative of employees. A copy of the notice shall be provided the employer or the employer's agent no later than at the time of the inspection. Upon request of the person giving notice, the person's name and the names of individual employees referred to in the notice shall not appear in the copy or on any record published, released, or made available pursuant to Subsection (7).

(ii)(A) If upon receipt of the notice the division's authorized representative determines there are reasonable grounds to believe that a violation or danger exists, the authorized representative shall make a special inspection in accordance with this section as soon as practicable to determine if a violation or danger exists.

(B) If the division's authorized representative determines there are no reasonable grounds to believe that a violation or danger exists, the authorized representative shall notify the employee or representative of the employees in writing of that determination.

34A6203 (1) A person may not discharge or in any manner discriminate against any employee because:
(a) the employee has filed any complaint or instituted or caused to be instituted any proceedings under or related to this chapter;
(b) the employee has testified or is about to testify in any proceeding; or
(c) the employee has exercised any right granted by this chapter on behalf of himself or others.

(2) (a) Any employee who believes that the employee has been discharged or otherwise discriminated against by any person in violation of this section may, within 30 days after the violation occurs, file a complaint with the division in the commission alleging discrimination.
(b)(i) Upon receipt of the complaint, the division shall cause an investigation to be made.
(ii)The division may employ investigators as necessary to carry out the purpose of this subsection.
(c) If the investigator reports a violation and the employer requests a hearing on the alleged violation, the commission shall hold an evidentiary hearing to determine if provisions of this subsection have been violated.
(d) If the commission determines that a violation has occurred, it may order the violation to be restrained and may order all appropriate relief, including reinstatement of the employee to his former position with back pay.(1987)

34A6307(5)(c) Any person who knowingly makes a false statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this chapter is guilty of a class A misdemeanor.

INSTRUCTIONS

Complete items 1 through 17 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 symptoms of employees at your site) include the information in your description.

1. Establishment Name:

NOTE: In order for OSHA to fully process your complaint, complete and accurate information about the worksite is necessary.

2. Site Street:

3. Site City:

4. Site State:

5. Site Zip Code:

6. Mailing Address (if Different):

7. Management Official:

8. Telephone Number:

9. Type of Business:

10. Hazard Description. Describe briefly the hazard(s) which you believe exist. Include the approximate number of employees exposed to or threatened by each hazard:

11. Hazard Location. Specify the particular building or worksite where the alleged violation exists:

12. This condition has been brought to the attention of: (Choose all that apply)

Employer

Other Government Agency (Specify):

13. I am a(n):

Employee

Former Employee

Federal Safety and Health Committee

Representative of Employees

Other: (Specify)

OPTIONAL:
The OSH Act 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.

14. Please indicate your desire:

Do NOT reveal my name to my Employer

My name may be revealed to my Employer

15. Complainant Name:

16. Complainant Telephone Number:

17. Complainant Mailing Address (Street, City, State, Zip)

18. Complainant E-mail Address:

19. 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:

Punishment for Unlawful Statements

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 Section 17(g) 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.

Public reporting burden for this 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 instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of IRM Policy, Department of Labor, Room N-3101, 200 Constitution Avenue, NW, Washington, DC 20010: and to the Office of Management and Budget, Paperwork reduction Project (1218-0064), Wash. DC 20503.

Utah Labor Commission

Electronic (on-line) Complaint Form for Reporting Alleged Safety/Health Hazards

Punishment for Unlawful Statements

Electronic (on-line) Complaint Form
for Reporting Alleged Safety/Health Hazards