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Industrial Commission of Arizona

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

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  • Home
  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
    • Legislation
      • Arizona Statutes
      • Arizona Rules
    • Meetings
      • All Public Meetings
      • Commission Meeting Agendas
      • Meeting Minutes
  • Divisions
    • Administration
      • 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
    • Resources for Insurers
    • Resources for Medical Providers
    • Resources for ICA Community
  • How Do I
  • Online Services
    • Forms
    • Self Service Center
    • ICA Community
  • Payment Portal
  • OMBUDSMAN
  • Home
  • ADOSH Discrimination Complaint Form

ADOSH Discrimination Complaint Form

 

An employee may use this form to file a discrimination complaint if the employee believes the employer has retaliated against the employee for exercising employee rights under the Arizona Occupational Safety and Health Act. Submission of this form constitutes filing a discrimination complaint pursuant to Arizona Revised Statutes (A.R.S.) section 23-425.

It is not necessary to use this form. ADOSH will accept a discrimination complaint made orally (telephone or walk-in) or in writing, and in any language. An employee may also file a complaint or obtain more information by contacting ADOSH Discrimination Investigations at 602-542-5355 or by contacting ADOSH toll free at (855) 268-5251.

This form must include an accurate description of each allegation of retaliation (what happened). The description should include specific evidence supporting the allegation.  IMPORTANT: the information contained in this complaint will be shared with the employer including the complainant’s identity. A whistleblower complaint filed with ADOSH cannot be filed anonymously.

This form can be submitted online by selecting the link below, or it can be submitted to ADOSH by mail, fax, or hand-delivery. ADOSH requires that the complainant sign the complaint allegation.  To access a printer friendly form that you can fill out and mail, fax or hand-deliver to ADOSH, select this link..

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. 

 

 

Required Forms

Form Name Last Updated
Discrimination / Whistleblower Complaint Form 03/20/23
Discrimination / Whistleblower Complaint Form 03/20/23

Official Website of the State of Arizona

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Contact Us:

Phoenix Office
800 W. Washington Street
Phoenix AZ 85007
602-542-4661

 

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Contact Us:

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716
520-628-5188

 

 

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