Notice of Alleged Safety or Health Hazard

Indicates required field

Employer Business Name

Management Official

Street Address

Site City/Town

Site ZIP/Postal Code

Is the site location and mailing address the same?

Yes

Mailing Address

City/Town

State/Province

ZIP/Postal Code

Phone number

Type of Business

Hazard Description

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

Hazard Location

Specify the particular building or work site where the alleged violation exists.

This condition has been brought to the attention of

Employer

Other Government Agency

I am a(n)

Former Employee

Current Employee

Federal Safety and Health Committee

Representative of Employees

Other…

Status message

It is the policy of OSH not to reveal the names of complainants to the employer. However, providing your name and telephone number to our department will enable us to provide you with inspection/investigation findings, and assist you if questions arise.

Reveal or Do Not Reveal My Name

Do NOT reveal my name to my Employer

My name may be revealed to my Employer

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 NCDOL staff communicate with you regarding your complaint.

Complainant Name

This constitutes my electronic signature (If the box labeled "Agree" is checked, the submission shall be considered an authorized signature.) Agree

Complainant Email

Complainant Phone Number

Complainant Address

Complainant Address 2

Complainant City/Town

Complainant State/Province

Complainant ZIP/Postal Code

Are you an authorized representative of employees affected by this complaint?

Yes

Organization Name

Your Title

By checking this box, I hereby certify that the information provided on this form is truthful and accurate to the best of my knowledge. I understand that, per North Carolina General Statute Chapter 95, Article 16, Occupational Safety and Health Act of North Carolina (N.C. Gen. Stat. §95-139(e)), anyone knowingly making any false statement, representation, or certification in any document filed pursuant to this Article shall be guilty of a Class 2 misdemeanor, punishable by up to 60 days in jail and a fine of up to twenty thousand dollars ($20,000).

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