Information

  • CLIENT:

  • CONTACT AND PHONE #

  • Location
  • Requested on:

  • Prepared by:

QA Audit

OSHA Complaints

  • Written complaint or visit

  • COMPLAINT IS:

  • complaints
  • LIST COMPLAINTS

OSHA requested information or items checklist

  • OSHA compliance officer assigned: [name and info]

  • Date of visit

  • Check if visit is for complaint.

  • DATE / TIME OF INCIDENT / ACCIDENT

  • Notes on request

  • status

  • Add media

  • Copy of site specific health and safety program

  • status

  • Add media

  • Copy of Toolbox talks / Safety Meetings

  • status

  • Add media

  • Number of employees on this site and all sites

  • status

  • answer to above:

  • legal name of company & owners or corporate officers

  • status

  • Answer to above

  • Federal Tax ID #

  • status

  • Answer to above:

  • NAICS code #

  • status

  • Answer to above:

  • Complete mailing address and phone # for corporate office & regional office [if applicable]

  • status

  • Answer to above:

  • Official name and address of project [if applicable]

  • status

  • Answer to above:

  • Check if other information requested [list below]

  • item or information
  • List Other Information or items

  • status

  • does hazzard still exist

  • Union ?

  • Union, local, shop steward or business agent information

  • injured overnight stay or other required report

  • OSHA notified by

  • Date and time OSHA notified

  • Notes on injury;

  • injured is employee of?

  • Subcontractor info:

  • Injured info:

  • Witnesses:

  • Witness Information

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.