Form Miosha Gi 516 – Fill Out and Use This PDF

Full Name:*

Date of Hire:*

Job Title and Department:*

Case No. (office use only)

Address:*

City:*

State:*

Zip Code:*

Telephone No.*

Present Status:*

Still Employed

Laid Off

Discharged

Suspended

days

Employer :*

Address:*

City*

State:*

Zip Code:*

County:

Telephone No.:*

Supervisor or Contact Person:

Union:*

Union & Local No.

Union Address:

Yes

No

Have you filed a

If so, date your

Status of your

No. of Employees:

Average Hours

Rate of Pay*

grievance?

grievance was filed:

grievance:

Worked*

Yes

No

Did you file a complaint

Date you filed

Who did you file the

If you filed a complaint with MIOSHA was it?

Was your name

of safety or health?*

complaint:

complaint with?

revealed to employer?

Yes

No

General Industry

Construction

Yes

No

Date and time discrimination occurred:*

Why do you think you were discriminated against?*

Did you verbally complain of alleged

To whom, when and what were the results of your complaint:

unsafe/unhealthy conditions to employer:

Yes

No

Summary of Events:* (add additional sheets if necessary)

Date:

FOR OFFICE USE ONLY

TYPE OF BUSINESS

SIC CODE

NAICS CODE

Person who took complaint:

Investigator assigned to:

*Information Required to Complete Form

Return completed form to:

EMPLOYEE DISCRIMINATION SECTION

CADILLAC PLACE  3026 W. GRAND BLVD.  SUITE 9-450 

DETROIT, MICHIGAN 48202

MIOSHA-GI-516 (04/2011)

www.michigan.gov/miosha  (313) 456-3109  (313) 456-4226 FAX