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Michigan Occupational Safety and Health Administration (MIOSHA)

Michigan Occupational Safety and Health Administration (MIOSHA)

Safety and Health Hazards Complaint Form

It is unlawful to make any false statement, representation or certification in any document filed pursuant to the Michigan Occupational Safety and Health Act of 1974, as amended. Violators can be punished by a fine of not more than $10,000, or by imprisonment of not more than six months, or by both (Section 35(7)).


* = Required Fields

Establishment Information



BUSINESS SITE ADDRESS

State

MI

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BUSINESS MAILING ADDRESS (If Different from Business Site Address)

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Has this been brought to the attention of:

Complainant Information

Please indicate whether or not you want your name revealed

Please indicate your current employment status


The undersigned believes that a violation of an occupational safety or health standard exists which is a job safety or health hazard at the establishment named on this form.

Complaints with an electronic signature of the employee or employee representative are more likely to result in an onsite inspection. Complaints without a signature are more likely to be addressed by MIOSHA calling or faxing the employer a letter asking for a response to the complaint allegations.


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COMPLAINANT ADDRESS

If you wish to receive a copy of the results of this complaint, please provide your mailing address below.


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


LEO is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.