NOTICE OF ALLEGED SAFETY/HEALTH HAZARDS
"This form is provided for the assistance of any Complaint and is not intended to constitute the exclusive means by which a complaint may be registered with the Utah Occupational Safety and Health Division.
34A-6-301(6)(a)(i) Any employee or representative
of employees who believes that a violation of an adopted
safety or health standard exists that threatens physical
harm, or that an imminent danger exists, may request an
inspection by giving notice to the division's authorized
representative of the violation or danger. The notice shall
be in writing, setting forth with reasonable particularity
the grounds for notice, and signed by the employee or representative
of employees. A copy of the notice shall be provided the
employer or the employer's agent no later than at the time
of the inspection. Upon request of the person giving notice,
the person's name and the names of individual employees
referred to in the notice shall not appear in the copy or
on any record published, released, or made available pursuant
to Subsection (7).
(ii)(A) If upon receipt of the notice the division's
authorized representative determines there are reasonable
grounds to believe that a violation or danger exists, the
authorized representative shall make a special inspection
in accordance with this section as soon as practicable to
determine if a violation or danger exists.
(B) If the division's authorized representative determines
there are no reasonable grounds to believe that a violation
or danger exists, the authorized representative shall notify
the employee or representative of the employees in writing
of that determination.
34A-6-203(1) A person may not discharge or in any
manner discriminate against any employee because:
(a) the employee has filed any complaint or instituted
or caused to be instituted any proceedings under or related
to this chapter;
(b) the employee has testified or is about to testify
in any proceeding; or
(c) the employee has exercised any right granted
by this chapter on behalf of himself or others.
(2) (a) Any employee who believes that the employee
has been discharged or otherwise discriminated against by
any person in violation of this section may, within 30 days
after the violation occurs, file a complaint with the division
in the commission alleging discrimination.
(b)(i) Upon receipt of the complaint, the division
shall cause an investigation to be made.
(ii)The division may employ investigators as necessary
to carry out the purpose of this subsection.
(c) If the investigator reports a violation and the
employer requests a hearing on the alleged violation, the
commission shall hold an evidentiary hearing to determine
if provisions of this subsection have been violated.
(d) If the commission determines that a violation
has occurred, it may order the violation to be restrained
and may order all appropriate relief, including reinstatement
of the employee to his former position with back pay.(1987)
34A-6-307(5)(c) Any person who knowingly makes
a false statement, representation, or certification in any
application, record, report, plan, or other document filed
or required to be maintained under this chapter is guilty
of a class A misdemeanor.
INSTRUCTIONS
Complete items 1 through 17 as accurately and completely as possible. Describe each hazard you think exists in as much detail as you can. If the hazards described in your complaint are not all in the same area, please identify where each hazard can be found at the worksite. If there is any particular evidence that supports your suspicion that a hazard exists (for instance, a recent accident or physical symptoms of employees at your site) include the information in your description.
After you have completed the form, return it to:
LABOR COMMISSION
UTAH OCCUPATIONAL SAFETY & HEALTH DIVISION
160 EAST 300 SOUTH
P O BOX 146650
SALT LAKE CITY UT 84114-6650
Telephone: (801)-530-6901
FAX Number: (801)-530-7606
NOTE:
The filing of a Complaint does not automatically instigate an inspection of the company, an investigation of the allegations will be made.
1. Employer Name: _________________________________________________________
2. Site Location (Street, City, State, Zip) :
_______________________________ _________________________________________
3. Mailing Address (If different) (Street, City, State, Zip) :
_________________________________________________________________________
4. Management Official :
_________________________________________________________________________
5. Telephone Number FAX Number: _________________________________________________________________________
6. Type of Business :
_________________________________________________________________________
7. Hazard Description (Describe briefly the hazard(s) which you believe exists. Include the approximate number of employees exposed to or threatened by each hazard. (Use another page if needed.) _________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
8. Hazard Location (Specify particular building or worksite where the alleged violation exists).
_________________________________________________________________________
9. Has this condition been brought to the attention of (Mark "X" in all that apply.)
[ ] Employer [ ] Other
Government Agency (Specify) _______________________________
10. Please indicate:
[ ] Do not reveal my name to the Employer. [ ] My name may be revealed to Employer.
11. The Undersigned: Believes that a violation of an Occupational Safety/Health standard exists which is a job safety/health hazard at the establishment named on this form.
My Status: (Mark "X" in one box)
[ ] Employee [ ] Ex-Employee (Reason for leaving, when) _____________________________ [ ]Federal Safety/Health Committee [ ] Employer [ ] Other (Specify) ___________________ [ ] Representative Employees ________________________________________________
12. Complainant Name (Type or print name) :
_________________________________________________________________________
13. Address (Street, City, State, Zip) :
_________________________________________________________________________
14. Signature _________________________________
15. Date _________________________
16. Telephone Number ___________________________
17. 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:______________________________________ Title:_______________________________________________
Rev 8-6-97