Da Form 4755 – Fill Out and Use This PDF

EMPLOYEE REPORT OF

ALLEGED UNSAFE OR UNHEALTHFUL WORKING CONDITIONS

For use of this form, see AR 385-10; the proponent agency is Office of The Inspector General.

This form is provided for the assistance of any complainant and is not intended to constitute the exclusive means by which a complaint may be registered with the local Safety Office (Ref OSHA Poster on rights of employees and their representatives).

Does this hazard (s) immediately threaten serious physical harm?					Yes	No
If "yes" checked, immediately contact your supervisor or safety representative.
Name of official in charge							Telephone
Operation/Activity
Exact location of worksite

1. Kind of operation

2. Describe briefly the hazard which exists there including the appropriate number of employees exposed to or threatened by such hazard

3.List by number and/or name the particular occupational safety and health standard(s) which may have been violated, if known

4.(a) To your knowledge, has this hazard been the subject of any union/management grievance or have you (or anyone you know) otherwise called it to the attention of, or discussed it with the employer or any representative thereof?

(b)If so, please give the results thereof, including any efforts by management to eliminate or reduce the severity of the hazard

5.Please indicate your desire:

I do not want my name revealed to the official in charge.

My name may be revealed to the official in charge.

WORK LOCATION		TELEPHONE NO.	DATE
TYPED OR PRINTED NAME OF EMPLOYEE OR EMPLOYEE	SIGNATURE
REPRESENTATIVE