California > Workers Comp > General
OSHAB Appeal Form - California
| OSHAB Appeal Form Form. This is a California form and can be used in General Workers Comp . |
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OCCUPATIONAL SAFETY AND HEALTH APPEALS BOARD 2520 Venture Oaks Way, Suite 300 Sacramento, CA 95833 (916) 274-5751 FAX (916) 274-5785 APPEAL FORM DOCKET __________________________________ Inspection Number on Citation __________________________________ Employer Name on Citation __________________________________ Employer Legal Name or DBA (Optional) __________________________________ Address __________________________________ __________________________________ ____________ (Leave blank-Appeals Board will fill in.) 1. You only have 15 working days from receipt of a citation to appeal. 2. A copy of this form must be attached to each citation or notification appealed. Failure to file a completed form may result in dismissal of the appeal. FIRST READ IMPORTANT INFORMATION ON THE REVERSE SIDE THEN COMPLETE ONE APPEAL FORM FOR EACH CITATION 1. This is an Appeal from: [ ] CITATION NO(s): Item No(s): [ ] NOTIFICATION OF FAILURE TO ABATE ALLEGED VIOLATION Item No(s): CITATION NO(s): [ ] SPECIAL ORDER/SPECIAL ACTION NO: Item No(s): 2. Specific ground(s) for this appeal are: (Check all that apply) [ ] The safety order was not violated. [ ] The classification (i.e. serious, willful, repeat) is incorrect. [ ] The abatement requirements are unreasonable. [ ] Required changes [ ] Time allowed to complete changes [ ] The proposed penalty is unreasonable. 3. Explain any other reasons for appeal or issues to be raised on appeal. Affirmative defenses must be specifically stated. Some important affirmative defenses are listed on the OSHAB website at: http://www.dir.ca.gov/OSHAB/oshab.html American LegalNet, Inc. www.FormsWorkflow.com 4. (Signature of Employer or Employer's Representative) {If there is any change in representation after you file your appeal, you must notify the Appeals Board in writing} (Type or print name) (Title) (Address) {Address where all communications from the Appeals Board will be sent} (City) (State) (Zip Code) (Telephone) (E-Mail Address) (Date) {All correspondence from the Appeals Board will be sent to the representative above at the address above. If there is any change in address, telephone number, and/or e-mail address after you file your appeal, you must notify the Appeals Board of the change(s). All such notifications must be in writing} IMPORTANT INFORMATION A. Use this form to appeal a Citation, Notification of Failure to Abate Alleged Violation, or Special Order/Special Action. B. You must complete a separate appeal form for each citation or notification you wish to appeal and attach a copy of the complete citation or notification that you are appealing. C. If the citation or notification being appealed includes more than one item do not use separate appeals forms for each item. Instead, specify the items you are appealing in the space provided in No. 1 on the front of this form. (for example, "Citation No. 1, Item Nos. 2, 5, and 8) D. Be sure to sign your appeal form and provide all the information requested in No. 4 above. E. Your appeal form shall be deemed not completed unless you attach a copy of each citation or notification that you are appealing, and failure to file a completed appeal form may result in dismissal of the appeal. F. If you or your representative change address, telephone number, and/or e-mail address, it is your responsibility to notify the Appeals Board in writing of the change(s). Otherwise the Appeals Board will continue to use the address it has on file and you risk not receiving notices or other communications from the Appeals Board. Appeals Board regulations make it the employer's obligation to notify the Appeals Board of any changes to the employer's and/or representative's contact information. G. Mail each completed Appeal form and citation or notification to the Occupational Safety and Health Appeals Board, 2520 Venture Oaks Way, Suite 300, Sacramento, CA 95833. H. Late appeals will not be accepted unless good cause is shown. OSHAB 5/08 American LegalNet, Inc. www.FormsWorkflow.com
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