Workplace Safety Complaint Form

Chapter 292, RSMo

For more information about free workplace safety programs, visit www.labor.mo.gov/SAFE.

To mail, print this form and send to:
Division of Labor Standards
Attn: Workplace Safety Program
P.O. Box 449, Jefferson City, MO 65102-0449
Phone: 573-751-3403      Fax: 573-751-3721
E-mail: workplacesafety@labor.mo.gov
If you are an employee within the public sector and are concerned about safety and health conditions at your facility, please complete and submit the following form. If you are an employee within the private sector, the Occupational Safety and Health Administration (OSHA) has jurisdiction over your issue. You may contact OSHA at the Kansas City office at 800-892-2674 or the St. Louis office at 800-392-7743.
 Date:
 
Complainant Name
Last Name,
, 		First Name
   		Middle Intl.
  		Suffix
 
 
 
 
 
 
 
 
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(Please note: If there are errors and this form reloads, you will need to re-select your files)
  
 
 
 
 
  * If you are unable to attach the documentation electronically, please indicate below in the "Summary of Complaint" a brief description of documentation you have. An investigator may contact you and ask to have it mailed or faxed to our agency if the documentation is needed.  
 
 
 
   
By entering my name and submitting this electronically,
I do hereby affirm under penalties of perjury that the above-stated information is true and correct to the
best of my knowledge, information, and belief.