Fillable Comp Unsafe Workplace (Office of the Chief Information Officer)

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Comp Unsafe Workplace (Office of the Chief Information Officer)

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The Comp Unsafe Workplace (Office of the Chief Information Officer) form is 1 page long and contains:

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  • 19 check-boxes
  • 57 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Office of the Chief Information Officer

BROWSE OFFICE OF THE CHIEF INFORMATION OFFICER (IA) FORMS

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Iowa Division of Labor
OSHA Enforcement
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5660
Fax: 515-725-2024
www.iowaosha.gov
oshacomplaints@iwd.iowa.gov
Formal Non-Formal Close: Yes No
Diary sheet Database
updated: Yes No updated: Yes No
Complaint#: Case file #:
CSHO: NAICS: Transferred: Yes No
Instructions:
To file a complaint about a workplace safety or health issue, send this completed form and any attachment to the address above.
If you need more space you may continue on another page.
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
Employer name
Business type
Management official
Site address
City
Zip
Mailing address Same as site address
City
Zip
Phone number
Fax number
Email address
Describe violation of OSHA standard
Location
# exposed
This condition has been brought to the attention of: Employer Other Agency (specify):
Which best describes you: Current employee Former employee Employee representative
Other (specify):
Your name
Email
Phone number
Address
City
Zip
I certify that the information on this form and the attachments (if any) is true and accurate to the best of my knowledge
Signature
Date
Complete this section if you are an authorized representative of the affected employee
Organization
Name
Title
03.18.2020
700-001
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.
FOR OFFICE USE ONLY
Complaint Form
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Comp Unsafe Workplace (Office of the Chief Information Officer)

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Completed 20 July 2020

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