Notice Of Alleged Health Or Safety Hazards

E M P L OY E N A M E : E M P L OY E R A DD R E S S : E M P L OY E M A IL I NG A DDR E SS : M A N A G E M E NT O FFIC I A L : E M P L OY E T E L EP H O N E NU M B E R: F A X : N A T U RE O F E M P L OY E B U S I N E S S : D E S CRI B E FULLY T HE H A Z A RD S T H A T YO U B E L I E V E EX I S T INCLUDING T HE NU M B E R O F E M P L OY E E S E X P OS E D: S P E CIFY E A C H L O C A T I O N O R WO RK A R E A W H E RE T HE H A Z A R DS D E S C RIB E D A B OV E EX I S T : T HIS C O NDI T I O N H A S B E E N BR O U G HT T O T HE A T T E N T I O N O F : ( Check a l l t h a t a p pl y ) E M P L OY E R F E D E R A L O S H A O T H E R ( S pe c i f y ) : N A M E O F P E R S O N FILING C O M P L A IN T : T E L EP H O N E : M A ILING A D DR E SS : R E L A T I O N S HIP T O E M P L OY E R : E M P L OY E E O T H E R ( S pe c i f y ) : IF P E R S O N FIL I NG C O M P L A INT IS A N E M P L OY E E R E P R E SE N T A T I V E , W H A T O R G A NI Z A T I O N D OE S T HE C O M P L A I N A NT R E P R ES E NT ( Pr o v ide t he name a nd local # of the organi z a t ion and y our title, if ap p r op r iate ) : T HE ID E N T I T Y O F T HE P E R S O N FI L ING T HIS C O M P L A INT W ILL BE R E V E A L E D T O T HE E M P L O Y E R UN L E S S T HE R E L E A S E O F T HE N A M E W ILL R ES U L T IN S UBS T A N T I A L H A RM T O T HE PE R S O N FI L ING T HE C O M P L A IN T . P L E A S E INDI C A T E T HE F O LL OW IN G : M Y N A M E M A Y B E R E VE A L E D DO N O T R EV E A L M Y N A M E T O T HE E M P L OY E R B E C A U S E : CURRENT DATE: NOTICE OF ALLEGED SAFETY OR HEALTH HAZARDS THE INDUSTRIAL COMMISSION OF ARIZONA DIVISION OF OCCUPATIONAL SAFETY & HEALTH SIGNATURE: : American LegalNet, Inc. www.FormsWorkFlow.com