Submit a request – Tennessee Department of Labor and Workforce Development

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Your email address

Subject

Description

Check here if you are a current employee:

Only click this box if you are a current employee of the workplace. TOSHA maintains complainant confidentiality to the extent permitted by law. TOSHA evaluates every complaint to determine if an on-site inspection is needed, if a process of calling the employer will enable the alleged hazard to be addressed with documentation provided via e-mail, or if the complaint falls outside of TOSHA's jurisdiction. If you submit a complaint as "anonymous" you will not be provided the results of the complaint evaluation.

Do you wish to remain anonymous?

I am the following:

Other (specify)

Complainant Name/Person Completing Form

Complainant email address.

Complainant Mailing Address

Please include street address or PO Box, city, state and ZIP Code

Telephone Number

The Undersigned

Select an option below

If former employee, enter separation date

Employee Rep. Organization Name

Employee Representative Name

Representative Title/Relation to Employee(s)

Representative Phone Number

Representative Email

Confirmation Box Check

By checking this box, you are electronically signing your name to the complaint. Your electronic signature is valid to formalize this complaint if: you have provided your valid name, AND provided accurate contact information, such as a phone number, that TOSHA may use to contact you. Additionally, the affected employee should have requested, or at least approved, the filing of the complaint on their behalf. If false or incomplete information is provided, the complaint will not be considered signed and cannot be accepted as a formal complaint.

Employer / Establishment Name / Department

Type of business

Employer Site Address (Must include Street, City, State, ZIP Code)

Include Street, City, State, ZIP code

Employer Mailing Address: (If different from site)

Include Street, City, State, ZIP Code

Management Official Name

Employer Phone Number

Employer Email

Has the condition been brought to the attention of:

If Other Government Agency, please specify

Hazard Description

Briefly describe the workplace hazard(s) which you believe exist. Include the following for each alleged violation: description of the hazard, specific location where the hazard exists, and approximate number of employees exposed to or impacted by the hazard. Example 1: 12-foot-deep trench, no benching or trench box onsite, 123 Main Street Nashville, 3 workers exposed Example 2: Guards removed from the press I use, boss refuses to fix, Press Department, 4 workers exposed

Hazard Location / Building / Department

Number of Workers Exposed

How are you aware of the hazard(s)? Select option that best applies

The hazard(s) is/are: (Select option that best applies)

Date hazard occurred

To request an inspection, an employee or their representative shall put their complaint in writing and shall sign the complaint per T.C.A. Section 50-3-304(a)(2).

By checking this box, you are electronically signing your name to the complaint. Your electronic signature is valid to formalize this complaint if: you have provided your valid name, AND; provided accurate contact information, such as a phone number, that TOSHA may use to contact you. If false or incomplete information is provided, the complaint will not be considered signed and cannot be accepted as a formal complaint. Note: Unsigned complaints or complaints NOT originating from employees, or their representatives may not result in an onsite inspection.

Date of request

Note: T.C.A. Section 50-3-502 states, “Any person who knowingly makes any false statement, representation or certification in any application, record, report or other document filed or required to be filed or maintained pursuant to the provisions of this chapter commits a Class C misdemeanor.”

Attachments

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