INDUSTRIAL COMMISSION OF ARIZONALABOR DEPARTMENTP. O. Box 19070 Phoenix, Arizona 85005542-4515PUBLIC COMPLAINT REFERRAL REPORT1.Date:2.CL No.:3.Business Name:Corporation:Franchise:4.Address:Phone:City:State:Zip Code:5.Type of Business:6.Number of Employees:7Ownership:8.CorporationSoleName of Principals (s) Owner(s): Manger(s):ProprietorshipSupervisor:Government Agency FranchisePartnership9.Referred by:Compliance10.ADOSHOther Govt.Date Received: 11.Field VisitComplianceAgencyType of Contact:Legal Dept.CitizenTelephoneLetterOtherSpecial FundMedia12.Possible violation description (Include specifics, e.g. name (s) and age (s) of youth (s), work site, type of possible violation, etc.):Youth's Name:Age:D.O.B.Address:City:Zip Code:State:Work Phone No.:Home Phone No.:Duties:13.Occupation Violation:14. Hours Violation:Imminent DangerSeriousSeriousVery SeriousOtherNo LongerNo LongerOtherThereThere15.Potential Witness (es) (Include name, location, affiliation, telephone number):Anonymous (Keep confidential)Name:Address: City:Zip Code:State:Work Phone No.:Home Phone No.:17. If yes, priority?16.Inspection Planned?18. If no, reason?YesNo20. Date:19.Send letter?21 Response due:TakeYesNoWith22.Other Information:2001 © American LegalNet, Inc.23.Investigator:24. Supervisor:Date:Date:2001 © American LegalNet, Inc.
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