Illinois OSHA Safety and Health Complaint Form

Note: Illinois OSHA only has jurisdiction over public sector employers . Examples of public sector employers include: municipal employers (example: public works departments), city employers (example: police and fire departments) , county employers (example: Cook County Health and Hospital Systems), State of Illinois offices and agencies (example: Illinois Department of Transportation, State Board of Education, Illinois Tollway Authority, Illinois Department of Public Health). If your complaint is about a private sector employer (example: gas stations, manufacturer, retail business establishment, restaurant, etc) then you must contact Federal OSHA, who has jurisdiction over all private sector businesses and establishments. They can be reached by calling 1-800-321-OSHA (6742) or by visiting: www.osha.gov/pls/osha7/eComplaintForm.html

Notice of Alleged Safety or Health Hazards Form

For the Illinois Public Sector

Establishment Name

Site Address

Site Phone

Site Fax

Mailing Address

Mailing Phone

Mailing Address Fax

Management Official

Management Phone

Business Type

# of Employees Exposed to the Hazard

Hazard Description Describe briefly the hazard(s) which you believe exist.

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

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

Employer
Other Government agency

Other Government Agency Notified

Please indicate your desire: The OSHA Act gives complainants the right to request that their names not be revealed to their employer. Providing your name and address will only allow Illinois OSHA staff to communicate with you regarding your complaint

Do NOT reveal my name to my Employer
My name may be revealed to my Employer

I am a(n):

Employee
Representative of Employees
Safety and Health Committee
Other

Other (Specify)

Complainant Name

This constitutes my electronic signature.

(If this box is checked, this submission shall be considered as an authorized written signature. The Complainant is also acknowledging that he/she has read the Illinois OSHA Instructions and all applicable laws, rules, and regulations incorporated within.)

Complainant Phone

Complainant Address

Complainant E-Mail Address

Organization NameIf you are an authorized representative of employees affected by this complaint, please state the name of the organization that you represent and your title.

Your Title

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Illinois OSHA Safety and Health Complaint Form

Notice of Alleged Safety or Health Hazards Form

For the Illinois Public Sector

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Illinois OSHA Safety and Health Complaint Form

Notice of Alleged Safety or Health Hazards Form

For the Illinois Public Sector

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