Although no particular form is required for a complaint, OSHA did publish a proposed form on January 17, 2013. The form starts on page 16 of the notice published here.
To file the complaint, review the text to make sure it all fits the case at hand, and then sign it. The complaint must be signed by the complainant or by a person authorized by complainant to make the complaint on his or her behalf. OSHA will accept complaints that are faxed, mailed, or hand delivered. A fax number at OSHA's HQ is 202-693-1659. The complaint can be filed in any local OSHA office. Be sure to check if the number is correct and your complaint is received. You can find local offices by clicking here, although changes are not always posted promptly. You can find a list of these and other federal whistleblower protections here.
It is now OSHA policy to accept oral complaints. You can call any OSHA office to make a complaint. However, OSHA's record of properly recording and processing oral complaints is less than perfect. Filing a written complaint will give you more control over how it is written.
UNITED STATES DEPARTMENT OF LABOR
OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
[complainant's name and address]
[respondent's name and address]
[If another entity participated in the retaliation, list its name and address; otherwise, omit this bracketed sentence, and change references to "respondents" to the singular.]
OSHA Case No.
COMPLAINT OF RETALIATION AGAINST WHISTLEBLOWER
1. Complainant [name] alleges violations of the
employee protection provisions of the following laws as indicated:
/_/ Energy Reorganization Act of 1974, 42 U.S.C. § 5851
/_/ Toxic Substances Control Act, 15 U.S.C. § 2622
/_/ Safe Drinking Water Act, 42 U.S.C. § 300j-9(i)
/_/ Water Pollution Control Act (WPCA, commonly called the Clear Water Act or CWA), 33 U.S.C. 1367
/_/ Solid Waste Disposal Act (SWDA), 42 U.S.C. § 6971, also called the Resource Conservation and Recovery Act (RCRA)
/_/ Clear Air Act (CAA), 42 U.S.C. § 7622
/_/ Comprehensive Environmental Response, Compensation and Liability Act of 1980 (CERCLA or "Superfund Law") , 42 U.S.C. § 9610 (1988)
/_/ International Safe Container Act of 1977, 46 U.S.C. § 1506
/_/ Surface Transportation Act (STA), 49 USC § 31105
/_/ Mine Safety and Health Act (MSHA), 30 USC § 815(c)
/_/ Asbestos Hazard Emergency Response Act of 1986, 15 U.S.C. § 2651
/_/ Wendell H. Ford Aviation Investment and Reform Act for the 21st Century ("AIR 21"), 49 U.S.C. § 42121
/_/ Pipeline Safety Improvement of 2002 (PSIA), 49 U.S.C. § 60129
/_/ Sarbanes-Oxley Act of 2002 (SOX), 18 U.S.C. § 1514A
/_/ Federal Rail Safety Act (FRSA), 49 U.S.C. § 20109
/_/ National Transit Systems Security Act of 2007 (NTSSA), 6 U.S.C. § 1142
/_/ Consumer Product Safety Improvement Act (CPSIA), 15 U.S.C. § 2087
/_/ FDA Food Safety Modernization Act (FSMA), 21 U.S.C. § 399d
/_/ Affordable Care Act (ACA), 29 U.S.C. § 218C
/_/ Dodd-Frank consumer financial protection provision, 12 U.S.C. § 5567
/_/ Seaman's Protection Act, 46 U.S.C. § 2114
/_/ Moving Ahead for Progress in the 21st Century Act (MAP-21), 49 U.S.C. § 30171
2. Complainant [name] is [or was] an employee of the respondent [name of employer]. [Respondent [name] also participated in the unlawful adverse actions.] Complainant worked for [employer] for about _____ years. Complainant's duties included _______________________________________.
3. Complainant engaged in protected activity. [Or, respondents believed complainant engaged in protected activity.] Complainant's protected activities include, but are not limited to,
raising compliance issues with management
collecting evidence of violations
communicating with appropriate enforcement authorities to report violations
refusing to engage in unlawful conduct
raising compliance concerns with others who might reasonably have been effective at commencing enforcement proceedings
participating in enforcement proceedings by making a complaint, initiating proceedings, or by being identified as a witness.
During relevant times, respondents either knew of complainant's protected activity, or suspected complainant of engaging in protected activity.
4. Respondents have discriminated against complainant and maintained a hostile work environment for complainant on account of protected activities. Such hostility, discrimination and retaliation includes, but is not limited to:
A. Denying complainant a raise.
B. Reducing complainant's bonus.
C. Imposing discipline on complainant.
D. Subjecting complainant to hostile interrogation
E. Giving complainant a poor performance evaluation.
F. Relieving complainant of duties
G. Confiscating the complainant's property
H. Revoking complainant's access
I. Damaging complainant's reputation and future employment opportunities.
J. Respondent has restrained complainant and other employees from engaging in protected activity.
K. Discharging complainant from employment on [date].
L. Placing complainant on leave or relieving complainant of duties.
M. Denying complainant a promotion.
5. Respondents maintained a hostile work environment for complainant, and otherwise discriminated against complainant on account of protected activities. Complainant has suffered loss of benefits, mental anguish, loss of reputation, and loss of advancement opportunities.
6. Complainant's address and telephone number are
7. The address and telephone number of respondent ________ are:
8. The address and telephone number of respondent ________ are:
9. Complainant is seeking the following relief:
B. Back pay, raises, bonuses, benefits, overtime, reinstatement of seniority and tenure, and other orders necessary to make complainant whole.
C. Abatement. An order (1) requiring respondent to abate and refrain from any further violations of the whistleblower provisions of the Acts; (2) requiring respondent to explicitly rescind any and all policies that restrain or direct employees in connection with reporting of compliance issues; (3) requiring respondent to prohibit harassment of those who engage, or are suspected of engaging in protected activity; (4) requiring respondent to take prompt and effective action against any reported violations.
D. An order expunging complainant's discipline, and ordering respondent to remove any records of disciplinary action against complainant, to preserve them only in the files of their legal counsel, and to use them only for purposes of defending rights in this proceeding.
E. An order prohibiting respondent from disclosing any disparaging information about complainant to prospective employers, or otherwise interfering with any applications he might make in the future.
F. Compensatory monetary damages in an amount determined to be fair and equitable compensation for complainant's emotional distress and loss of reputation.
G. Exemplary damages (permitted by TSCA, SDWA, STAA, FRSA, NTSSA) in an amount sufficient to deter respondent from future violations of the law.
H. Reasonable attorney fees for complainant's attorneys.
I. Costs of this litigation, including reimbursement for deposition fees, travel expenses, and other expenses to collect and produce evidence in this matter.
J. Posting. Complainant requests an order requiring respondent to issue a notice, and provide copies to all its employees that (1) the Department of Labor has found that respondent violated the rights of a whistleblower, [name], and ordered that this person be made whole, (2) describes the laws protecting whistleblowers, setting out the ALJ's orders to respondent as policies of respondent, (3) provides the name and address where complaints of violations may be sent, (4) informs employees that complaints must be filed within specified time limits after any adverse action.
Respectfully submitted by:
Name and address [person signing may be complainant or any person authorized by complainant to file the complaint, such as an attorney or union representative]