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

EMERGENCY NOTICE

Do Not Report an Emergency Using this Form or Email!

To report a work-related fatality, inpatient hospitalization, amputation or loss of an eye please immediately call:

217-782-7860

Please fill out the form below, but READ THIS FIRST. Items noted with an asterisk(*) are required in order to accept your submission.

For the Illinois Public Sector

* indicates required field

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:

Employer

Other Government Agency

Choose all that apply

Other Government Agency Notified

Please indicate your desire:

Do NOT reveal my name to my Employer

My name may be revealed to my Employer

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

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 or 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 Name

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.

Your Title

Illinois OSHA Safety and Health Complaint Form

Notice of Alleged Safety or Health Hazards Form

EMERGENCY NOTICE

For the Illinois Public Sector

Helpful Links

IDOL

Illinois OSHA Safety and Health Complaint Form

Notice of Alleged Safety or Health Hazards Form

EMERGENCY NOTICE

For the Illinois Public Sector

Footer

Helpful Links

IDOL