DOLI Virginia Occupational Safety and Health Complaint Form

About the Employer
Establishment Name*
Note: In order for VOSH to fully process your complaint, complete and accurate information about the worksite is necessary.
Physical Address*
Please enter the address for the business's physical address in the state of Virginia
Click here if the physical address is outside of Virginia

Street Address

City

ZIP Code
Mailing Address

Same as Physical Address

Street Address

City

State

ZIP Code
Owner/Supervisor Name
Business Phone Number
Type of Business
Number Of Employees

About The Issue
Hazard Description*
Describe briefly the hazards(s) which you believe exist. Include the approximate number of employees exposed to or threatened by each hazard.
Hazard Location*
Specify the location in a particular building and/or the location on a worksite where the alleged violation/s exists.
This condition has been brought to the attention of:
Choose all that apply
- No One
- Employer
- Other Government Agency (Please specify below)
What Government Agency was notified of the condition?

About You
I am a/an:*
- Former Employee
- Current Employee
- Immediate Relative of a Current Employee (i.e Spouse, Parent, Child)
- Representative of Employees
- Personal Physician of a Current Employee
- Member of a Federal Safety Committee
- Other
- None of the above - I wish to remain anonymous
What is the name of your Union or Bargaining Committee?*
What is the name of the Committee?*
Please explain your choice of other:*
Complainant Name*

First

Last
This constitutes my electronic signature
(If this box is checked, this submission shall be considered as an authorized written signature.)
Complainant Telephone Number*
Complainant Mailing Address

Street Address

City

State

ZIP Code
Complainant Email Address*

Enter Email

Confirm Email
Email
This field is for validation purposes and should be left unchanged.

Virginia Occupational Safety and Health Complaint Form