Pesh 7 Form – Fill Out and Use This PDF

New York State Department of Labor

Public Employee Safety and Health Bureau

Notice of Alleged Safety or Health Hazards

For the General Public:

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 New York State Department of Labor.

Section 27a(5)(a) of the Public Employee Safety and Health Act of 1980 provides as follows: "Any employee or representative of employees who believes that a violation of a safety or health standard exists, or that an imminent danger exists, may request an inspection by giving notice to the commissioner (of Labor) of such violation or danger. Such notice and request shall be in writing, shall set forth with reasonable particularity the grounds for the notice, shall be signed by such employee or representative of employees, and a copy shall be provided by the commissioner to the employer or the person in charge no later than the time of inspection, except that on request of the person giving such notice, his name and the names of individual employees or representatives of employees shall be withheld. Such inspections shall be made forthwith." If the Commissioner of Labor determines there are no reasonable grounds to believe that a violation or danger exists, the Commissioner shall notify the employees or representative of the employees in writing of such determination.

Note: Section 27a (10) (a) of the Act provides explicit protection for employees exercising their rights, including making safety and health complaints.

Instructions:

Complete as accurately and completely as possible. Describe each hazard you think exists in as much detail as you can. If the hazards described in your complaint are not all in the same area, please identify where each hazard can be found at the worksite. If there is any particular evidence that supports your suspicion that a hazard exists (for instance, a recent accident or physical symptoms of employees at your site) include the information in your description. If you need more space than is provided on the form, continue on any other sheet of paper.

After you have completed the form, return it to nearest DOSH district office listed below:

Division of Safety and Health District Offices

Public Employee Safety and Health Bureau

ALBANY 12240	BINGHAMTON 13901	BUFFALO 14202
State Office Campus Bldg. #12	44 Hawley Street – Rm. 901	65 Court St – Rm. 400
Rm. 158	Tel: (607) 721-8211	Tel: (716) 847-7133
Tel: (518) 457-5508	FAX: (607) 721-8207	FAX: (716) 847-7108
FAX: (518) 485-1150
GARDEN CITY 11530-6551	NEW YORK CITY	ROCHESTER 14607
400 Oak Street - Suite 101	75 Varick Street (7thFl.)	109 S. Union St. – Rm. 402
Tel: (516) 228-3970	New York, NY 10013	Tel: (585) 258-4570
FAX: (516) 794-7714	Tel: (212) 775-3548	FAX: (585) 258-4593
	FAX: (212) 775-3542
SYRACUSE 13202	UTICA 13501	WHITE PLAINS 10605
450 S. Salina St. – Rm. 401	207 Genessee St. – Rm. 703A	120 Bloomingdale Rd. - Rm. 255
Tel: (315) 479-3212	Tel: (315) 793-2258	Tel: (914) 997-9514
FAX: (315) 479-3451	FAX: (315) 793-2303	FAX: (914) 997-9528

PESH 7 (1-11)

			Complaint Number
Establishment Name
Site Address
	Site Phone		Site FAX
Mailing Address
	Mail Phone		Mail FAX
Management Official			Telephone
Type of Business

Hazard Description/Location. Describe the hazard(s) which you believe exist (be specific). Include the approximate number of employees exposed to or threatened by each hazard. Specify the particular building or worksite where the alleged violation exists. Use additional sheets if necessary.

Has this condition been brought to the	฀ Employer	฀ Other GovernmentAgency
attention of:		(specify)
Please Indicate Your Desire:	฀ Do NOT reveal my nameto my Employer
	฀ My namemay berevealed totheEmployer
The Undersigned believes that a violation	(Mark √ in ONE box)
of an Occupational Safety or Health	฀ Employee	฀ Safety and Health Committee
standard exists which is a job safety or
Health hazard at the establishment named	฀ Representativeof Employees	฀ Other (specify) ________________
on this form:
Complainant Name
Telephone Number
Address (Street, City, State, Zip)

If you are an authorized representative of employees affected by this complaint, please state the name of the organization that you represent and your title:

Organization Name:	Your Title:

2