Electronic (on-line) Complaint Form for
Reporting Alleged Safety/Health Hazards

Formulario Electrónico de Quejas para Notificar
Presuntos Peligros de Seguridad/Salud Laboral

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. You may also download and print this form in Spanish or English for your convenience, if needed.

Este formulario se proporciona para facilitar el proceso de quejas y no constituye el único medio por el cual se pueden presentar quejas con la División de Salud y Seguridad Ocupacional de Utah.  Para su conveniencia, este formulario tambien se puede descargar en inglés o español.

NOTE:  In order for OSHA to fully process your complaint, complete and accurate information about the worksite is necessary. 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.

Por favor complete los encasillados 1 al 17 de este formulario.  Describa cada peligro de seguridad y salud laboral que usted crea que existe con el mayor detalle posible.  Si los peligros de trabajo descritos en su queja no se encuentran en la misma zona, identifique dónde se puede encontrar cada peligro laboral.  Si hay alguna prueba espec√≠fica que apoye su sospecha de que existe un peligro (por ejemplo, un reciente accidente o síntomas físicos de los empleados en el lugar de trabajo), incluya esa información en su descripción del peligro laboral.

RequiredRequired Fields

RequiredCampos Obligatorios

1. Employer Name:Nombre de la empresa:Required
2. Site AddressDirección del lugar de trabajoRequired  
  Street AddressCalle
  City, State, ZipCiudad, Estado, Código Postal ,  
3. Mailing Address:
(if different)
Dirección Postal:
(si es diferente)
4. Management OfficialNobre del Gerente o Supervisor:
5. Telephone NumberNúmero de teléfono: 000-000-0000
6. Type of BusinessTipo de negocio o trabajo:
7. Hazard DescriptionDescripción del riesgo/peligro laboralRequired  
  Describe briefly the hazard(s) which you believe exist.  Include the approximate number of
employees exposed to or threatened by each hazard
Describa brevemente el(los) peligro(s) que usted cree que existe(n). Incluya el número aproximado de empleados expuestos a cada peligro:
8. Hazard LocationUbicación del peligroRequired
  Specify the particular building or worksite where the alleged violation existsEspecifique el edificio o zona particular donde el peligro existe:
9. This condition has been brought to the attention ofEsta condición/peligro ha sido señalada o comunicada a la atención de:Required
Other Public Sector Agency (Specify):Otra Agencia de Gobierno (especifique):

No OneNadie
10. I am a(n)Yo soy:Required  
Former Employee Ex-empleado
Representative of EmployeesRepresentante personal del trabajador
Federal Safety and Health CommitteeMiembro del comité de salud/seguridad
Other: (Specify)Otro: (especifique)
11. The Occupational Safety and Health Act gives complainants the right to request that their names not be revealed to their employer.  Providing your name and address, will only allow OSHA staff to communicate with you regarding your complaint. La ley de Seguridad y Salud Ocupacional de Utah le proporciona a los querellantes el derecho de solicitar que sus nombres no sean revelados a su empleador. Proporcionar su nombre y dirección en este formulario, sólo permitirá que Utah OSHA pueda comunicarse con usted en relación a su queja.
  Please indicate your desirePor favor indique:Required
  Do NOT reveal my name to my EmployerNo quiero que se revele mi nombre a mi empleador
My name may be revealed to my EmployerMi nombre puede ser revelado a mi empleador
12. Your NameNombre:Required
  This constitutes my electronic signature.
(If this box is checked, this submission shall be considered as an authorized written signature.)
Esto constituye mi firma electrónica.
(Si esta cassia está marcada, esta presentación será considerada como una firma escrita autorizada.)
13. Your Phone NumberTeléfono:Required 000-000-0000
14. Your Mailing AddressDomicilioRequired
  Street AddressCalle
  City, State, Zip CodeCiudad, Estado, Código Postal ,  
15. Your E-mail Address:Dirección de correo electrónico:
16. 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: Si usted es un representante autorizado de los empleados afectados por esta queja, indique el nombre de la organización y su titulo:
  Organization NameOrganización:
  Your TitleTitulo:

Punishment for Unlawful Statements

El Castigo por Delaraciones ilegales

Potential complainants should keep in mind that it is unlawful to knowingly make any false statement, representation, or certification in any complaint. Violators may be punished under Utah Code Ann. 34A-6-307(5)(c), and found guilty of a class A misdemeanor.

Cualquier persona que a sabiendas haga una declaración, representación, o la certificación falsa en cualquier aplicación, registro, informe, plan u otro documento presentado, o que requiera ser mantenido en virtud del capitulo presente, es culpable de un delito menor de clase A.

The Law

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.

We welcome your questions or comments

160 East 300 South, 3rd Floor
P O Box 146650
Salt Lake City, UT 84114-6650