Notice of Alleged Safety or Health Hazard ichoyle Submitted by ichoyle on Mon, 01/04/2021 - 15:52 This is to be completed only for businesses or employers in North Carolina. Indicates required field Employer Business Name Management Official Address Street Address Site City/Town Site ZIP/Postal Code Is the site location and mailing address the same? Yes No Mailing Address Mailing Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming 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 Enter Other Agency I am a(n) Former Employee Current Employee Federal Safety and Health Committee Representative of Employees Other… Other Type of Person 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 contact Complainant Email Complainant Phone Number Complainant Address Complainant Address 2 Complainant City/Town Complainant State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Complainant ZIP/Postal Code Are you an authorized representative of employees affected by this complaint? Yes No 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).
