The Notice of Alleged Safety or Health Hazards Form

ADOSH will address each complaint received, but how each complaint is handled will depend on several factors, including: the nature of the complaint items, the seriousness of the allegations, the relationship of the complainant to the employer, and whether or not the complaint is signed. While you may fill out the form, save it on your computer, then submit it as an attachment to an email, doing so will prevent you from signing the complaint form, which may affect the manner in which ADOSH addresses your complaint. If you wish to submit a signed complaint, you will need to print the completed form, sign it, then FAX it or submit it via regular postal service to an address or FAX number above. Alternatively, you can scan the signed form, then submit that as an email attachment to the email address above.

Notice of Alleged Safety or Health Hazards Form (English)