Maryland Occupational Safety and Health (MOSH)

ONLINE COMPLAINT FORM

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.

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.

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.

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.

Please complete all sections. Items noted with an asterisk (*) are required fields.

1. Company Name:*

2. Company Mailing Address:

Street Address:*

City:*

State:*

ZIP:*

County:*

3. Worksite Location:* Is worksite location different from Company Mailing Address ?		YES		NO

Please complete worksite location address fields.

Street Address:*

City:*

State:*

ZIP:*

County:*

4. Company Telephone Number:*

Ext:

5. Management Official in Charge:*

6. Type of Business:*

Description of occupational safety or health hazard. Describe each occupational safety or health hazard to which you believe employees are exposed. Indicate the approximate number of employees exposed to or threatened by each hazard.*

Limit 2350 Characters

8. Hazard location. Identify the specific building, room, or worksite where each alleged hazard is located.*

Limit 1000 Characters

9. This condition has been brought to the attention of: (Choose all that apply)

	Employer

	Other Government agency (specify)

10. The undersigned complainant is a(n):*

Current Employee

Former Employee

Employer

Immediate Relative of a Current Employee (i.e Spouse, Parent) Specify:

Authorized Representative of Employees (you must indicate the organization and your title)

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:

Organization Name:*

Your Title:*

Other: (Specify)

11. Complainant Name:

First Name *

Last Name *

12. Complainant Home or Cell Phone Number:*

13. Complainant Home Mailing Address:*

Street Address:*

City:*

State:*

ZIP:*

14. Complainant Email Address:*

15. Signature:*

I believe there is a violation of a safety or health standard, a danger that threatens physical harm, or an "imminent danger" exists.

16.

This constitutes my electronic signature.*

If this box is checked, this submission shall be considered as an authorized written signature.