PEOSH Complaint Form
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* Indicates Required Field
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Public Employee Occupational Safety & Health
Notice of Alleged Safety & Health Hazards |
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(no dashes e.g. 555554444) |
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(no dashes e.g. 5554443333) |
(no dashes e.g. 5554443333) |
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(no dashes e.g. 555554444) |
Hazard Description & Location |
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A copy of this form may be provided to the employer upon request per 51 O.S.24A.1 et seq. |
Pursuant to 51 O.S.§ 24A.14, the Department of Labor may, in its discretion, keep confidential the identity of anyone making a complaint. |
The undersigned believes that a violation of an occupational safety or health standard exists which is a job safety or health haazard at the establishment indicated on this form (above). |
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(Format: mm/dd/yyyy)
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(no dashes e.g. 555554444) |
(no dashes e.g. 5554443333) |
(no dashes e.g. 5554443333) |
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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. |
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Submission of this form requires Internet Explorer 9.0 or higher (with Compatibility Mode off), Firefox, or Google Chrome. |
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