CONN-OSHA Online Complaint Form

CONN-OSHA Online Complaint Form

Notice of Alleged Safety or Health Hazards
This form is for Public Employees in the State of Connecticut. Employees in the private sector should refer to: www.osha.gov/workers/file_complaint.html

EMERGENCY NOTICE
Do Not Report an Emergency Using this Form!

To report an emergency, fatality, or imminent life-threatening
situation please contact us immediately:

Local (860) 263-6946 Toll Free (866) 241-4060
1. Establishment Name: *
Note: In order for CONN-OSHA to fully process your complaint, complete and accurate information about the worksite is necessary.
2. Site Street: *
3. Site City: *
4. Site State:
5. Site ZIP Code: *
6. Mailing Address (if different):

Street Address

Street Address Line 2

City State

Zip Code
7. Management Official:
8. Telephone Number:
9. Type of Business:
10. Hazard Description. *
Describe briefly the hazards(s) which you believe exist. Include the approximate number of employees exposed to or threatened by each hazard.
11. Hazard Location. *
Specify the particular building or worksite where the alleged violation exists.
12. This condition has been brought to the attention of: (Choose all that apply)

Employer
13. I am a(n): *

Former Employee Current Employee Representative of Employees
The OSH Act gives complainants the right to request that their names not be revealed to their employer. Providing your name and address, will only allow CONN-OSHA staff to communicate with you regarding your complaint allegations.
14. Please indicate your desire: *

Do NOT reveal my name to my Employer My name may be revealed to my Employer
15. Complainant Name: *
16. Complainant Telephone Number: *
If this box is checked, this submission shall be considered as an authorized written signature. *

This constitutes my electronic signature.
17. Complainant Mailing Address

Street Address

Street Address Line 2

City State

Zip Code
18. Complainant E-Mail Address: *
19. 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:
Punishment for Unlawful Statements
Potential complainants also should keep in mind that it is unlawful to make any false statement, representation, or certification in any complaint. Violations can be punished under C.G.S. Section 31-382(g) by a fine of not more than $10,000, or by imprisonment of not more than 6 months, or by both.
Should be Empty: