OSHA Whistleblower Complaint Form

OSHA WHISTLEBLOWER COMPLAINT FORM

U.S. Department of Labor - Occupational Safety and Health Administration

CRITICAL DEADLINE NOTICE

FILING DEADLINES VARY BY STATUTE:

Your Deadline Calculation:

Date of Retaliation: _________________________________

Applicable Statute: _________________________________

Filing Deadline: _________________________________

PART I: COMPLAINANT INFORMATION

Section A: Personal Information

Full Legal Name: _________________________________

Other Names Used: _________________________________

Date of Birth: _________________________________

Last 4 Digits of SSN: _________________________________

Current Address:

Street: _________________________________

City: _________________ State: _______ ZIP: _________

Mailing Address (if different):

_____________________________________________________________________________

Contact Information:

Home Phone: _________________________________

Cell Phone: _________________________________

Work Phone (if safe to call): _________________________________

Email Address: _________________________________

Preferred Contact Method: ☐ Phone ☐ Email ☐ Mail

Best Times to Reach You: _________________________________

May OSHA leave a message? ☐ Yes ☐ No

Language Preference: _________________________________

☐ Interpreter needed - Language: _________________________________

Section B: Representative Information (if applicable)

Are you represented by an attorney or other representative?
☐ No
☐ Yes

If yes:

Name: _________________________________

Organization/Firm: _________________________________

Address: _________________________________

Phone: _________________________________

Email: _________________________________

☐ I authorize this representative to receive all communications regarding my complaint

PART II: EMPLOYER (RESPONDENT) INFORMATION

Section A: Primary Employer

Company/Organization Name: _________________________________

Also Known As/DBA: _________________________________

Type of Business: _________________________________

Industry: _________________________________

Address:

Street: _________________________________

City: _________________ State: _______ ZIP: _________

Telephone: _________________________________

Website: _________________________________

Number of Employees:
☐ 1-15
☐ 16-100
☐ 101-500
☐ Over 500

Union Representation?
☐ No
☐ Yes - Union Name: _________________________________

Section B: Management/HR Contacts

Your Direct Supervisor:

Name: _________________________________

Title: _________________________________

Phone: _________________________________

Human Resources Contact:

Name: _________________________________

Title: _________________________________

Phone: _________________________________

Person Who Made Decision to Retaliate:

Name: _________________________________

Title: _________________________________

Phone: _________________________________

Section C: Additional Respondents

Are there other companies or individuals responsible?
☐ No
☐ Yes

If yes:

Name: _________________________________

Relationship to Primary Employer: _________________________________

Address: _________________________________

Role in Retaliation: _________________________________

PART III: EMPLOYMENT DETAILS

Section A: Your Employment

Job Title: _________________________________

Department: _________________________________

Work Location:

_____________________________________________________________________________

Date of Hire: _________________________________

Type of Employment:
☐ Full-time
☐ Part-time
☐ Temporary
☐ Contract
☐ Seasonal

Work Schedule: _________________________________

Current Employment Status:
☐ Currently employed
☐ Terminated - Date: _________________________________
☐ Resigned - Date: _________________________________
☐ Laid off - Date: _________________________________
☐ On leave - Type: _________________________________

Section B: Compensation

Pay Rate: $_________________ per ☐ Hour ☐ Week ☐ Month ☐ Year

Average Hours Per Week: _________________________________

Overtime Pay: ☐ Yes ☐ No Rate: $_________________

Benefits:
☐ Health Insurance
☐ Dental Insurance
☐ Retirement/Pension
☐ Paid Time Off
☐ Other: _________________________________

Section C: Performance Record

Performance Reviews:

Most Recent Rating: _________________________________

Date: _________________________________

Prior Ratings: _________________________________

Any Prior Disciplinary Actions?
☐ No
☐ Yes - Describe:

_____________________________________________________________________________

PART IV: PROTECTED ACTIVITY

Section A: Type of Protected Activity

Select the statute that applies to your complaint:

Workplace Safety:
☐ OSHA Section 11(c) (29 U.S.C. § 660(c)) - Occupational safety and health complaints
☐ MSHA - Mine Safety and Health Act

Transportation:
☐ STAA - Surface Transportation Assistance Act (trucking)
☐ FRSA - Federal Railroad Safety Act
☐ NTSSA - National Transit Systems Security Act
☐ AIR21 - Wendell H. Ford Aviation Investment and Reform Act
☐ SPA - Seaman's Protection Act
☐ PSIA - Pipeline Safety Improvement Act

Environmental:
☐ CAA - Clean Air Act
☐ CERCLA - Comprehensive Environmental Response, Compensation, and Liability Act
☐ FWPCA - Federal Water Pollution Control Act (Clean Water Act)
☐ RCRA - Resource Conservation and Recovery Act (Solid Waste Disposal Act)
☐ SDWA - Safe Drinking Water Act
☐ TSCA - Toxic Substances Control Act

Nuclear/Energy:
☐ ERA - Energy Reorganization Act (nuclear safety)

Financial/Corporate:
☐ SOX - Sarbanes-Oxley Act
☐ CFPA - Consumer Financial Protection Act

Healthcare:
☐ ACA - Affordable Care Act

Consumer Protection:
☐ CPSIA - Consumer Product Safety Improvement Act
☐ FDA Food Safety Modernization Act

☐ Other: _________________________________

Section B: Description of Protected Activity

What protected activity did you engage in?

☐ Filed a complaint about safety/health/legal violations
☐ Reported a violation to a government agency
☐ Reported a violation internally to employer
☐ Refused to perform work you believed to be dangerous or illegal
☐ Participated in a safety inspection
☐ Testified or participated in a proceeding
☐ Exercised rights under applicable statute
☐ Other: _________________________________

Detailed description of your protected activity:

What did you report, refuse to do, or participate in?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

To whom did you make the report/complaint?

_____________________________________________________________________________

When did you engage in the protected activity? (Include all dates)

_____________________________________________________________________________

How did you report or engage in the activity? (verbal, written, email, hotline, etc.)

_____________________________________________________________________________

What response did you receive?

_____________________________________________________________________________

Section C: The Underlying Safety/Legal Concern

Describe the safety, health, or legal violation you reported or were concerned about:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Did the condition pose an imminent danger?
☐ No
☐ Yes - Describe:

_____________________________________________________________________________

Section D: Evidence of Protected Activity

Documents supporting your protected activity:
☐ Written complaints
☐ Emails
☐ Text messages
☐ Hotline confirmation
☐ Government agency filings
☐ Meeting notes
☐ Other: _________________________________

PART V: ADVERSE ACTION (RETALIATION)

Section A: Type of Adverse Action

Check all retaliatory actions taken against you:

☐ Termination/Discharge
Date: _________________________________
Stated reason: _________________________________

☐ Suspension
Dates: __________ to __________
With/Without pay: _________________________________

☐ Demotion
From: _____________ To: _____________
Date: _________________________________

☐ Reduction in Pay
Previous: $_________ New: $_________
Date: _________________________________

☐ Reduction in Hours
Previous: _________ New: _________
Date: _________________________________

☐ Denial of Promotion
Position: _________________________________
Date: _________________________________

☐ Denial of Benefits
What benefits: _________________________________

☐ Transfer/Reassignment
From: _____________ To: _____________
Date: _________________________________

☐ Negative Performance Evaluation
Date: _________________________________

☐ Threats
Nature: _________________________________
Date: _________________________________
By: _________________________________

☐ Harassment/Intimidation
Description: _________________________________

☐ Blacklisting
Description: _________________________________

☐ Constructive Discharge (forced to resign)
Date: _________________________________

☐ Other:
_________________________________

Section B: Detailed Narrative of Retaliation

Describe in detail what happened:

Who took the adverse action? What did they do or say? When and where did it occur?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Section C: Timeline of Events

PART VI: CAUSAL CONNECTION

Section A: Knowledge

Did the decision-maker(s) know about your protected activity?
☐ Yes
☐ No
☐ Unknown

How did they know?

_____________________________________________________________________________

Section B: Timing

Date of Protected Activity: _________________________________

Date of First Adverse Action: _________________________________

Time Between: _________________________________

Section C: Evidence of Causation

Check all that support causation:

☐ Close timing between protected activity and retaliation
☐ Direct statements by management about your protected activity
☐ Departure from established policies
☐ Disparate treatment compared to others
☐ Pretextual reason for adverse action
☐ Prior positive performance history
☐ Hostility after protected activity
☐ Pattern of retaliation against others
☐ Other: _________________________________

Describe evidence showing the retaliation was because of your protected activity:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Section D: Employer's Stated Reason

What reason did your employer give for the adverse action?

_____________________________________________________________________________

Why is this reason false or pretextual?

_____________________________________________________________________________

_____________________________________________________________________________

PART VII: DAMAGES

Section A: Economic Losses

Lost Wages:

Last pay rate: $_________________ per _________________

Date of last paycheck: _________________________________

Lost wages to date: $__________________

Projected future lost wages: $__________________

Lost Benefits:

Health insurance: $_________________ per _________________

Retirement contributions: $__________________

Other benefits: $__________________

Other Economic Losses:

Job search expenses: $__________________

Moving expenses: $__________________

Other: $__________________

TOTAL ECONOMIC DAMAGES: $__________________

Section B: Non-Economic Damages

☐ Emotional distress
☐ Anxiety/Depression
☐ Humiliation
☐ Damage to reputation
☐ Physical symptoms
☐ Medical treatment needed
☐ Other: _________________________________

Describe non-economic harm:

_____________________________________________________________________________

_____________________________________________________________________________

PART VIII: RELIEF REQUESTED

☐ Reinstatement to former position

☐ Back Pay with interest

☐ Front Pay (if reinstatement not feasible)

☐ Compensatory Damages

☐ Punitive Damages (where available)

☐ Attorney's Fees and Costs

☐ Expungement of negative information from personnel file

☐ Neutral Reference

☐ Posting of Notice regarding whistleblower rights

☐ Preliminary Reinstatement (where available)

☐ Other:
_________________________________

PART IX: WITNESSES

Witnesses to Protected Activity

Witnesses to Retaliation

PART X: OTHER PROCEEDINGS

Have you filed any other complaints about this matter?
☐ No
☐ Yes

If yes:

Do you have an arbitration agreement with your employer?
☐ No
☐ Yes
☐ Unknown

PART XI: CERTIFICATION

I, _________________________, certify under penalty of perjury that:

1. The information provided in this complaint is true and correct to the best of my knowledge.

2. I authorize OSHA to investigate this complaint and contact my employer.

3. I understand that filing a false complaint may result in penalties.

4. I understand the filing deadline applicable to my complaint.

5. I agree to cooperate with OSHA's investigation.

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

STATE-SPECIFIC NOTES

California

California has its own OSHA program (Cal/OSHA) and Labor Code § 6310-6312 provides additional protections for reporting workplace safety violations. California Labor Code § 1102.5 provides broad whistleblower protections. Employees may file with state or federal OSHA.

New York

New York operates under federal OSHA jurisdiction for private sector workers. Public employees are covered by the NY PESH program. New York Labor Law § 740 provides additional whistleblower protections with a 2-year statute of limitations.

Texas

Texas operates under federal OSHA jurisdiction. The Texas Whistleblower Act only covers public employees. Private sector workers must rely on federal OSHA and other federal whistleblower statutes.

Florida

Florida operates under federal OSHA jurisdiction. Florida Whistleblower Act (Fla. Stat. § 448.102) provides protections for private sector employees (10+ employees). Public employees have protections under Fla. Stat. § 112.3187.

HOW TO FILE

Online (Preferred)

OSHA Online Whistleblower Complaint Form:
https://www.osha.gov/whistleblower/wbcomplaint

By Telephone

OSHA Hotline: 1-800-321-OSHA (6742)
Complaints may be made verbally

By Mail/Fax/Email

Contact your local OSHA Regional or Area Office:
https://www.osha.gov/contactus/bystate

In Person

Visit your local OSHA office

WHAT HAPPENS AFTER FILING

1. Acknowledgment: OSHA sends acknowledgment within days
2. Notification: OSHA notifies employer of complaint
3. Investigation: OSHA investigates (target: 90 days for 11(c))
4. Determination: OSHA issues findings
5. Appeal: Either party may request ALJ hearing (30 days)
6. Federal Court: For some statutes, you may file in federal court

ATTACHMENTS CHECKLIST

☐ Completed complaint form
☐ Documents evidencing protected activity
☐ Termination letter or other adverse action documents
☐ Performance reviews
☐ Pay stubs
☐ Employment contract (if any)
☐ Witness contact information
☐ Any other relevant documents

This template is provided for educational purposes only and does not constitute legal advice. OSHA whistleblower complaints have strict filing deadlines that vary by statute. The 30-day deadline for OSHA Section 11(c) is particularly short. Consult an attorney immediately if you believe you have been retaliated against for protected activity.