The Michigan Occupational Safety & Health Administration (MIOSHA), within the Department of Licensing and Regulatory Affairs, provides a significant safeguard to employees across the state through mechanisms like the MIOSHA Discrimination Complaint Form, known formally as MIOSHA-GI-516. This form facilitates a crucial reporting process for workers who believe they have faced discrimination due to voicing concerns about safety or health conditions at their workplace. In a bid to ensure comprehensive protection, the form meticulously gathers details about the employee's work history, the nature of the complaint, and specifics about the employer and any union affiliations. With sections requiring information on previous grievances, the filing of safety or health complaints, and a summary of events leading to perceived discrimination, the form is structured to provide MIOSHA with a thorough understanding of each case. This process not only underscores the rights of workers to seek a safe working environment without fear of retribution but also highlights the dedication of Michigan's authorities to uphold these protections. By covering various aspects such as the immediate status of the employee, specifics about the incident, and procedural follow-ups, the MIOSHA-GI-516 form embodies the procedural gateway for addressing and investigating claims of workplace discrimination grounded in the pursuit of health and safety.
| Question | Answer |
|---|---|
| Form Name | Form Miosha Gi 516 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | CIS_WSH_MIOSHA_ Discrimination_ Compaint_74429_ 7 miosha discrimination complaints form |
Michigan Department of Licensing and Regulatory Affairs
Michigan Occupational Safety & Health Administration
MIOSHA DISCRIMINAT ION COMPLAINT FORM
Full Name:* |
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Date of Hire:* |
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Job Title and Department:* |
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Case No. (office use only) |
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Address:* |
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City:* |
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State:* |
Zip Code:* |
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Telephone No.* |
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Present Status:* |
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Still Employed |
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Laid Off |
Discharged |
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Suspended |
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days |
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Employer :* |
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Address:* |
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City* |
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State:* |
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Zip Code:* |
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County: |
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Telephone No.:* |
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Supervisor or Contact Person: |
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Union:* |
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Union & Local No. |
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Union Address: |
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No |
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Have you filed a |
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If so, date your |
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Status of your |
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No. of Employees: |
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Average Hours |
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Rate of Pay* |
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grievance? |
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grievance was filed: |
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grievance: |
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Worked* |
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Did you file a complaint |
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Date you filed |
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Who did you file the |
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If you filed a complaint with MIOSHA was it? |
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Was your name |
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of safety or health?* |
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complaint: |
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complaint with? |
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revealed to employer? |
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General Industry |
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Construction |
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No |
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Date and time discrimination occurred:* |
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Why do you think you were discriminated against?* |
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Did you verbally complain of alleged |
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To whom, when and what were the results of your complaint: |
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unsafe/unhealthy conditions to employer: |
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No |
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Summary of Events:* (add additional sheets if necessary) |
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Date: |
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FOR OFFICE USE ONLY |
TYPE OF BUSINESS |
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SIC CODE |
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NAICS CODE |
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Person who took complaint: |
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Investigator assigned to: |
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*Information Required to Complete Form |
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Return completed form to: |
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EMPLOYEE DISCRIMINATION SECTION |
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CADILLAC PLACE 3026 W. GRAND BLVD. SUITE |
DETROIT, MICHIGAN 48202 |
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www.michigan.gov/miosha (313) |
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The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.