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This is a Arizona form that can be used for Workers Comp.
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ADOSH 70 NOTICE OF ALLEGED SAFETY OR HEALTH HAZARDS THE INDUSTRIAL COMMISSION OF ARIZONA DIVISION OF OCCUPATIONAL SAFETY & HEALTH EMPLOYER'S NAME: EMPLOYER'S ADDRESS: EMPLOYER'S MAILING ADDRESS: MANAGEMENT OFFICIAL: EMPLOYER'S TELEPHONE NUMBER: NATURE OF EMPLOYER'S BUSINESS: DESCRIBE FULLY THE HAZARDS THAT YOU BELIEVE EXIST INCLUDING THE NUMBER OF EMPLOYEES EXPOSED: FAX: SPECIFY EACH LOCATION OR WORK AREA WHERE THE HAZARDS DESCRIBED ABOVE EXIST: THIS CONDITION HAS BEEN BROUGHT TO THE ATTENTION OF: (Check all that apply) EMPLOYER NAME OF PERSON FILING COMPLAINT: MAILING ADDRESS: RELATIONSHIP TO EMPLOYER: EMPLOYEE OTHER (Specify): FEDERAL OSHA OTHER (Specify): TELEPHONE: IF PERSON FILING COMPLAINT IS AN EMPLOYEE REPRESENTATIVE, WHAT ORGANIZATION DOES THE COMPLAINANT REPRESENT (Provide the name and local # of the organization and your title, if appropriate): THE IDENTITY OF THE PERSON FILING THIS COMPLAINT WILL BE REVEALED TO THE EMPLOYER UNLESS THE RELEASE OF THE NAME WILL RESULT IN SUBSTANTIAL HARM TO THE PERSON FILING THE COMPLAINT. PLEASE INDICATE THE FOLLOWING: MY NAME MAY BE REVEALED DO NOT REVEAL MY NAME TO THE EMPLOYER BECAUSE: CURRENT DATE: SIGNATURE: _________________________________ American LegalNet, Inc. www.FormsWorkFlow.com The Industrial Commission of Arizona Division of Occupational Safety and Health This form is provided to assist an employee representative filing a complaint under A.R.S. § 23-408(F). This form does not constitute the exclusive means to file a complaint with the Division of Occupational Safety and Health ("Division"). Section 23-408.F. of the Arizona Occupational Safety and Health Act provides that an employee or employee representative may request the Division to conduct an inspection when: 1) The employee or employee representative believe that a violation of a safety or health standard exists that threatens physical harm, or 2) The employee or employee representative believe that an imminent danger exists. An employee or employee representative shall request an inspection under A.R.S. § 23-408(F) by giving written notice to the Director of the Division, or the Director's authorized representative. An employee or employee representative shall ensure that the written notice states with reasonable particularity the grounds for the notice and is signed by the employee or employee representative. The Division shall not disclose the employee's or employee representative's name upon either: 1) A request from an employee or employee representative not to reveal the employee's or employee representative's name because release of the name will result in substantial harm to the employee or employee representative, or 2) A determination by the Division that disclosure of the employee's or employee representative's name may result in substantial harm to any person or to the public health or safety. Upon receipt of a written notice under A.R.S. § 23-408(F), the Director shall determine whether there are reasonable grounds to believe that a violation or danger exists. If the Director determines that a violation or danger may exist, the Director shall conduct a special investigation under the Occupational Safety and Health Act as soon as practicable. If the Director determines that there are no reasonable grounds to believe that a violation or danger exists, the Director shall provide written notice to the employee or employee representative of that determination. NOTE: A person who knowingly makes any false statement, false representation, or false certification in any document filed under the Arizona Occupational Safety and Health Act is guilty of a class 2 misdemeanor. A.R.S. § 23-418(G). INSTRUCTIONS TO COMPLETE THE NOTICE OF ALLEGED SAFETY OR HEALTH HAZARDS: Complete all items as accurately and completely as possible. Describe each hazard you think exists in as much detail as you can. If the hazards described in the Notice are not all in the same area, please identify where each hazard can be found at the worksite. If there is any evidence that supports your suspicion that a hazard exists (for example, a recent accident or physical symptoms experienced by employees at the worksite), include the information in your description. If you need more space than is provided on the form, continue on another sheet of paper. (If you type more information into the large text boxes than can be seen all at once, any lines that end up hidden will be saved in the electronic copy of the form but will not appear if the form is printed.) HOW DO I SUBMIT THE FORM? This depends on whether or not you intend to sign the form. ADOSH will address each complaint received, but how each complaint is handled will depend on several factors, including: the nature of the complaint items, the seriousness of the allegations, the relationship of the complainant to the employer, and whether or not the complaint is signed. While you may fill out the form, save it on your computer, then submit it as an attachment to an email, doing so will prevent you from signing the complaint form, which may affect the manner in which ADOSH addresses your complaint. If you wish to submit a signed complaint, you will need to print the completed form, sign it, then FAX it or submit it via regular postal service to an address below. Alternatively, you can scan the signed form, then submit that as an email attachment to email@example.com. The Industrial Commission of Arizona Division of Occupational Safety and Health P. O. Box 19070 Phoenix AZ 85005-9070 FAX: (602) 542-1614 The Industrial Commission of Arizona Division of Occupational Safety and Health 2675 East Broadway Blvd Tucson AZ 85716-5303 FAX: (520) 322-8008 American LegalNet, Inc. www.FormsWorkFlow.com