Samaritan Hospital Systems Priorities Petition

Work Hazard Complaint Form

Oregon Occupational Safety and Health (OSHA) Complaint Form
Oregon OSHA only has jurisdiction over workplace safety and health issues.

If your complaint relates to enforcement of minimum wage or collection of wages owed, go to the Bureau of Labor and Industries, Wage and Hour Division: http://www.oregon.gov/BOLI/WHD/pages/index.aspx

For discrimination complaints, go to the Bureau of Labor and Industries, Civil Rights Division: http://www.oregon.gov/BOLI/CRD/pages/index.aspx

If you have a food safety concern, those issues are usually best addressed by a local county health department. Both the Oregon Health Authority and the Oregon Department of Agriculture regulate food borne illness: http://public.health.oregon.gov/HealthyEnvironments/FoodSafety/Pages/index.aspx

Please report the hazard in question using the form shown below.
Employer's Name *
Type of Business *
Employer's Address *
City *
State *
Zipcode (5 digits) *
County *
Telephone *
Employer's Email Address
Where can OSHA contact an employer representative
Contact Person First Name
Contact Person Last name
Description of Hazard *
Location of the Hazard *
Street address and where at the address is the hazard (room, building, etc)
This was Reported to (may select more than one option) *

My Supervisor The Safety Committee A coworker I haven't reported the hazard to anyone
If you select "Yes" to the question, "keep your identity confidential," the information below will not be provided to the employer.
Do you want to keep your identity cofidential *

Yes No
Which of the following describes you? *
We can't contact you or keep you informed unless you provide the following information.
First Name
Last Name
Your Email Address
Retype Email Address
Telephone
Mailing Address
City
State
Zipcode (5 digits)
Should be Empty:

Samaritan Hospital Systems Priorities Petition

Work Hazard Complaint Form

KAISER

HEALTHCARE

AIRPORT

SECURITY

JANITORIAL

LAUNDRY + TEXTILES

KAISER HEALTHCARE AIRPORT SECURITY JANITORIAL LAUNDRY + TEXTILES