State of New Jersey

PUBLIC EMPLOYEES

OCCUPATIONAL SAFETY AND HEALTH

COMPLAINT	STATE USE ONLY
Complaint No.	Date Rec’d
NAICS Code	Investigator Code
Completed By

Complainant Department

1.	Name of the Employer

2.	Telephone Number

( )
3.	Employer-Street Address (Mailing)

4.	Employer-City, State, Zip Code

5.	County

6.	Type (Check One)

State Agency County Municipality School Board Utility Authority

Other (specify):
7.	Hazard Location/Name of Building (Specify building and exact location where alleged violation exists. Use separate form for each building.)

8.	Floor and Room Number

9.	Site-Street Address

10.	Site-City State, Zip Code

11.	County

12.	Name of Person(s) in Charge

13.	Telephone Number

( )
14.	Briefly describe your complaint:

15.	Approximate Number of Employees in Area

a.	Are there employees who believe they have health problems related to the complaint?

Yes No	b.	Number of employees experiencing symptoms:

16.	Type of work done in the area (i.e., clerical, maintenance, firefighter)

17.	Materials handled (chemicals, cleaning compounds, etc.)

18a. To your knowledge, has there been a previous inspection related to the complaint?

Yes No	b.	If Yes, by whom?

c.	Date Inspected

d.	Outcome of Inspection

PUBLIC EMPLOYEES

OCCUPATIONAL SAFETY AND HEALTH

COMPLAINT

(Continued)	STATE USE ONLY
Complaint No.
19.	To your knowledge, has this complaint been the subject of any union/management grievance or have you (or anyone you know) otherwise called it to the attention of, or discussed it with, the employer or any representative thereof?

Yes No

If Yes, give the results thereof, including any efforts by management to correct the violation:

20.	Name of Union

21.	Local Number

22.	Name of Employee Representative

23.	Telephone Number

( )
24.	Title

THE INFORMATION BELOW WILL REMAIN CONFIDENTIAL UPON REQUEST!

25.	Please indicate your desire:

MAY YOUR NAME BE REVEALED TO THE EMPLOYER? YES NO*

*If you choose “No,” then please make sure that we have your home address (below) and an alternate phone number where you can be reached.

IF YES, DO YOU WANT TO BE PRESENT WHEN THE INSPECTION IS CONDUCTED? YES NO
26.	The complainant, whose signature appears below (check one):

Employee

Representative of Employees

Employer

Other (Specify):
27.	Name of Complainant (Print or Type)

28.	Signature	29.	Date

30.	Complainant Home-Street Address

31.	Complainant Home-City, State, Zip

32.	County

33.	Telephone Number

( )	34.	Best Time to Contact

IF YOU ARE AN AUTHORIZED REPRESENTATIVE OF EMPLOYEES AFFECTED BY THIS COMPLAINT, COMPLETE THE FOLLOWING:

35.	Name of Organization

36.	Your Organization Title

OCC-57

JUN 15	Page 2 of 2 Pages.

JUN 15	Page 1 of 2 Pages.

___________________________________________________________________________________________

occ-57, Complaint

OCC-57, Complaint, PEOSH, occupational, public employees occupational safety and health, OCC

ewhite

2007-12-17

NJDHSS