California Form Rh 1027 PDF Details

In the sprawling state of California, the safety and well-being of those working with or around sources of radiation are safeguarded by stringent regulations and oversight. Enter the California RH 1027 form, a crucial document provided by the California Department of Public Health, Radiologic Health Branch. This form serves as a vital tool for reporting violations of radiation control regulations or license conditions, as well as unsafe conditions. Designed to be accessible, it can be utilized by employees, their representatives, or employers of directly involved personnel to communicate concerns directly to the Department. The form requires detailed information about the alleged violation or unsafe condition, including the type of business, location, specific details of the concern, and whether the issue poses an imminent threat to health and safety. It also probes whether these concerns have been previously addressed by any other government agency or within the workplace through union or management channels. Importantly, the RH 1027 form includes provisions for confidentiality, allowing the complainant to control the disclosure of their identity or the information provided. This document underscores California's commitment to maintaining high standards of radiation safety and health, ensuring that those on the frontline are empowered to voice concerns without fear of reprisal.

QuestionAnswer
Form NameCalifornia Form Rh 1027
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesrh1027 rhb 1027 violation of regulations or license or unsafe conditions form

Form Preview Example

State of California–Health and Human Service Agency

California Department of Public Health

 

Radiologic Health Branch

RADIATION SAFETY COMPLAINT

(Violation of Regulations or License or Unsafe Conditions)

This form may be used by an employee, his representative, or an employer of a directly involved employee, to notify the Department of violation of radiation control regulations or license conditions or unsafe conditions with respect to any source of radiation. Mail completed and signed form to: California Department of Public Health, Radiologic Health Branch, MS 7610, Compliance Unit, P.O. Box 997414, Sacramento, CA 95899-7414. For more information, go to www.dhs.ca.gov/rhb or phone (916) 327-5106.

Complainant

 

 

 

 

For Office Use Only

Name (type or print)

 

 

 

Office

 

by

 

 

 

 

 

 

 

 

Position

 

 

 

 

 

 

 

 

 

 

 

 

Telephone

Written

In-person

 

 

 

 

 

 

 

Address (number, street)

 

 

 

Assignment

 

 

 

 

 

 

 

 

 

City

 

 

 

ZIP code

Investigation file number (mo/day/yr)

Date received

 

 

 

 

 

 

 

Telephone (home)

(Office)

 

 

Agency

 

Inspector

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Review will be responsibility of above named agency/inspector)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complainant (check one)

Employee

Employee‘s representative:

believes that a radiation safety violation or unsafe condition at the following place of employment exists:

Other:

Employer‘s name

Address (number, street)

 

Telephone

 

(

)

 

City

State

 

ZIP code

 

 

 

 

 

1.Type of business

2.Specify the particular building or work site where the violation or unsafe condition is located.

3. Name of employer‘s agent(s) in charge

Telephone number

 

(

)

Telephone number

( )

4.The violation or unsafe condition: Describe briefly the radiation safety violation or unsafe condition which exists, including the approximate number of persons exposed to or threatened by such violation or unsafe condition.

Does the violation or unsafe condition pose an imminent threat to health and safety?

Yes

No

5. If known, name and/or list the radiation control regulation sections and/or license conditions which have been violated:

RH 1027 (7/07)

Page 1 of 2

6. To your knowledge have these violations or unsafe conditions been considered by any government agency?

Yes

No

If yes, state name of agency

Approximate date it was considered

7. Is a complaint, alleging the same violations or unsafe conditions, being filed with any other government agency?

Yes

No

If yes, specify each agency name

Agency address (number, street)

City

State

ZIP code

8. Have you (or anyone you know) called these violations or unsafe conditions to the attention or discussed it with, the employer

Yes

No

 

 

or any representative thereof?

 

 

 

 

 

 

To your knowledge, have these violations or unsafe conditions been the subject of any union/management grievance?

Yes

No

 

 

 

 

 

 

 

If yes, give the results thereof, including any efforts by management to correct the violations or unsafe conditions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.Confidentiality:

a.I permit the Department to disclose my name.

b.I permit the Department to disclose the information herein.

10.I hereby certify that the above, to the best of my knowledge, is true and correct.

Yes

Yes

No

No

Signature of complainant

Date

City

For Office Use Only

Date serviced

Inspector

Date

Time

Requirements written:

Yes

No

Complaint acknowledged:

Letter

Telephone

Summary:

Supervisor signature

Date

RH 1027 (7/07)

Page 2 of 2

How to Edit California Form Rh 1027 Online for Free

Working with PDF files online is definitely simple with this PDF tool. Anyone can fill in California Form Rh 1027 here painlessly. The editor is constantly improved by our team, receiving new functions and turning out to be better. In case you are looking to get going, this is what it will take:

Step 1: Click on the "Get Form" button above. It will open up our pdf tool so that you can start filling out your form.

Step 2: After you start the tool, you will notice the document ready to be filled out. Other than filling out various blank fields, you may also do several other actions with the file, that is putting on any text, modifying the original text, inserting illustrations or photos, placing your signature to the document, and much more.

In an effort to finalize this document, make sure that you type in the information you need in each and every field:

1. Firstly, while filling in the California Form Rh 1027, start out with the area that features the subsequent blank fields:

Step number 1 of filling in California Form Rh 1027

2. Once your current task is complete, take the next step – fill out all of these fields - Specify the particular building, Name of employers agents in charge, Telephone number , Telephone number , The violation or unsafe condition, persons exposed to or threatened, Does the violation or unsafe, Yes, and If known name andor list the with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

The way to complete California Form Rh 1027 portion 2

3. The following segment is about To your knowledge have these, Yes, If yes state name of agency, Approximate date it was considered, Is a complaint alleging the same, Yes, If yes specify each agency name, Agency address number street, City, State, ZIP code, Have you or anyone you know, or any representative thereof, To your knowledge have these, and If yes give the results thereof - fill out each one of these blanks.

Step no. 3 for filling out California Form Rh 1027

Concerning If yes state name of agency and Approximate date it was considered, be sure you double-check them in this current part. These two are the most significant ones in this PDF.

4. This next section requires some additional information. Ensure you complete all the necessary fields - Confidentiality, a I permit the Department to, b I permit the Department to, Yes, Yes, I hereby certify that the above to, Signature of complainant, Date, City, Date serviced, Inspector, Date, Time, For Office Use Only, and Requirements written - to proceed further in your process!

A way to complete California Form Rh 1027 portion 4

Step 3: Once you have looked again at the details provided, press "Done" to conclude your document creation. Find your California Form Rh 1027 when you subscribe to a free trial. Immediately use the pdf file in your FormsPal account, along with any edits and changes being all synced! When you use FormsPal, you can complete documents without stressing about personal information breaches or data entries getting shared. Our protected platform makes sure that your personal information is stored safely.

California Form Rh 1027 isn’t the one you’re looking for?

Related Documents