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Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

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  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
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      • Arizona Statutes
      • Arizona Rules
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      • All Public Meetings
      • Commission Meeting Agendas
      • Meeting Minutes
  • Divisions
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      • Accounting
      • Human Resources, Special Services and MIS
      • Self-Insurance and Tax Office
    • Administrative Law Judge (ALJ) Division
    • ADOSH
      • Boiler Section
      • Elevator Section
      • Occupational Safety and Health (OSHA / ADOSH)
      • Research & Statistics (BLS)
    • Claims Division
    • Labor Department
    • Legal Division
    • Medical Resource Office (MRO)
    • Special Fund Division
  • News and Events
    • Public Notices
    • News and Events
  • Resources For
    • Resources for Employees
    • Resources for Employers
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    • Resources for Medical Providers
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  • Notice of Alleged Safety or Health Hazards Form

Notice of Alleged Safety or Health Hazards Form

Instructions

An employee or employee representative who believes that a violation of a safety or health standard or regulation exists that threatens physical harm or believes that an imminent danger exists may use this form to file a notice of alleged safety or health hazard under A.R.S. § 23-408(F).  

This form must include an accurate description of each hazard including where the hazard can be found at the worksite.   If there is evidence which supports that the hazard exists (for example, a recent accident or physical symptoms experienced by employees at the worksite), include the information in the description.  IMPORTANT:  Upon request of the complainant employee or employee representative filing this notice, the complainant’s name and address as well as the names of other employees referred to in the notice will not appear on any copy of this notice or any record published, released or made available.

This form can be submitted online or it can be submitted to ADOSH by mail, fax, or hand-delivery. ADOSH requires that the complainant sign the notice.

NOTE: A person who knowingly makes any false statement, false representation or false certification in any document filed under Arizona Occupation Safety and Health Act is guilty of a class 2 misdemeanor. A.R.S. § 23-418(G).

Español

Para acceder a la versión en español del formulario de firmar y enviar en línea, seleccione el siguiente enlace. 

Para acceder a la versión en español del PDF para imprimir, seleccione el siguiente enlace.

 

 

Sign and Submit Form

Notice of Alleged Safety or Health Hazards Form 202106

Printer-Friendly Form

PDF icon ADOSH Notice of Alleged Safety or Health Hazard Form-English.pdf

Related Forms

Report a Fatality or Severe Injury Form
Notice of Alleged Safety or Health Hazards Form
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ADOSH Training Request Form
Application for Permit to Install or Alter Elevator Form
Elevator Inspection (PEI) New Application
Request for Boiler Repair Form
Request for Boiler Certificate Form
Boiler Inspector (PBI) Renewal Application
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800 W. Washington Street
Phoenix AZ 85007
602-542-4661

 

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Tucson AZ 85716
520-628-5188

 

 

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