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Maryland Occupational Safety and Health (MOSH)
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ONLINE COMPLAINT FORM
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INSTRUCTIONS: This form is provided for use in filing a complaint with the Maryland Occupational Safety and Health (MOSH) program. An
employee or authorized representative of employees may file a complaint if the employee or representative believes in good faith that there is an
imminent danger to an employee or that because of a violation of an occupational safety and health standard there is a threat of physical harm to an
employee. In order for MOSH to fully process your complaint, the form must be complete and must be signed.
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Maryland law provides that only a current employee or authorized representative of employees may request that his or her name not be disclosed in
connection with a complaint.
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To file a complaint, complete the form as accurately as possible. Describe each hazard in as much detail as you can. If the hazards you describe are
not all in one area, identify the location of each hazard individually. If specific evidence, such as recent accident or physical symptoms at the
worksite supports your belief that a hazard exists, include that information in your description.
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When MOSH receives your complaint, the hazards you describe will be evaluated to determine whether an inspection is appropriate. If additional
information is needed, we will attempt to contact you by telephone. MOSH also will provide you with a response in writing, so please be sure your
complete name, address, and email are printed clearly and correctly.
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Please complete all sections. Items noted with an asterisk (*) are required fields.
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2. Company Mailing Address:
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13. Complainant Home Mailing Address:*
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I believe there is a violation of a safety or health standard, a danger that threatens physical harm, or an
"imminent danger" exists.
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If this box is checked, this submission shall be considered as an authorized written signature.
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