WASHINGTON WORK HAZARD FORM Work Hazard Complaint Form-WA Washington Division of Occupational Safety and Health Complaint Form Use this form to report an alleged safety or health hazard with the Washington State Department of Labor & Industries (L&I). 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 reported to L&I. You may choose to remain anonymous when reporting or if you provide your name and contact information, you can request confidentiality. If you see a worker in immediate danger and need help, call L&I at 1-800-423-7233. Complete the form with as much detail as possible. Date * - Month - Day Year Enter the date the complaint was filled out Employer Name * Enter the legal name of the employer or establishment Site Location * Enter street (or highway) address, city, state and zipcode of the work site where the alleged hazard exists. Mailing Address (if different) * Enter the mailing address for the establishment if it is different from the site address Name of Management/Supervisory Official * Enter the name of the owner, operator, or agent in charge of the work site Business Telephone Number * Enter a telephone at the establishment. This may be the number of the management official identified in question above or another number for the establishment Type of Business Describe the type of industrial activity performed at the workplace. For example, a complaint alleging an unsafe warehouse condition in an agricultural chemical plant would show "agricultural chemical plant" in this space, not "warehouse" Hazard Description * Describe the hazard(s) you believe exist. Include the approximate number of employees exposed to or threatened by each hazard Hazard Location * Specify the particular building/work site and the work shifts where the alleged hazard is coccurring Who else have you informed about this unsafe condition/practice (mark all that apply) * Employer Other government agency Other individual If 'Other government agency' is chosen in the above question, please specify Please list the name, job title and date person was notified Are you a current employee or employee representative of this employer * Yes No If you are a current employee or employee representative, please indicate your desire Do not reveal my name to the Employer My name may be revealed to the Employer Confidentiality Note: DOSH will only maintain confidentiality regarding the source of a complaint for an employee or employee representative that files a DOSh workplace safety and health complaint. The employee or employee representative must specifically request confidentiality. If the confidentiality section of the form has not been completed, or there are questions regarding the complainants request for confidentiality, DOSH will contact the complaintant prior to initiating a complaint inspection. The Undersigned believes that a violation of an Occupational Safety or Health standards exists which is a job safety or health hazard of the establishment named on the form (choose one) * Please Select Employee Representative of the Employee Other If 'Other' is chosen in the above question, please specify NOTE: If you wish to receive results of our inpection/investigation, complete the questions listed below. First Name Last Name Phone Number Mailing Address City State ZIP + 4 Signature Clear Date - Month - Day Year Date If you are an authorized representative of employee affected by the complaint, please state the name of your organization that you represent and your title Submit Should be Empty: KAISER HEALTHCARE AIRPORT SECURITY JANITORIAL LAUNDRY + TEXTILES KAISER HEALTHCARE AIRPORT SECURITY JANITORIAL LAUNDRY + TEXTILES KAISER HEALTHCARE AIRPORT SECURITY JANITORIAL LAUNDRY + TEXTILES
