Iowa Division of Labor
150 Des Moines Street
Des Moines, IA 50309-1836
Formal Non-Formal Close: Yes No
Diary sheet Database
updated: Yes No updated: Yes No
CSHO: NAICS: Transferred: Yes No
To file a complaint about a workplace safety or health issue, send this completed form and any attachment to the address above.
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It is illegal for an employer to retaliate against an employee who files an Iowa OSHA complaint. It is illegal to make a false
statement on this complaint form.
Do NOT reveal my name to the employer My name may be revealed to the employer
Mailing address Same as site address
Describe violation of OSHA standard
This condition has been brought to the attention of: Employer Other Agency (specify):
Which best describes you: Current employee Former employee Employee representative
I certify that the information on this form and the attachments (if any) is true and accurate to the best of my knowledge
Complete this section if you are an authorized representative of the affected employee
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
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