Notice of Alleged Safety or Health Hazards Form


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).


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