Maryland Occupational Safety and Health (MOSH)

WHISTLEBLOWER COMPLAINT FORM

Instructions

1.		By completing this form, you are filing a Whistleblower Complaint with the Assistant Commissioner MOSH. You may also file a complaint by mail to: Assistant Commissioner for MOSH Maryland Department of Labor Division of Labor and Industry 10946 Golden West Drive Suite 160 Hunt Valley, MD 21031

2.		You may also file a complaint with the: U.S. Department of Labor Occupational Safety and Health Administration 200 Constitution Avenue, N.W. Washington, D.C. 20210 (202) 693-2199

3.		Your complaint must be filed within thirty (30) days of the act of discrimination. You cannot wait for the result of a related safety and health enforcement action or grievance process before filing your complaint.

4.		The complaint must be related to an occupational safety and health issue. Race discrimination and sex discrimination are NOT covered by the MOSH Act. These and many other types of employment discrimination, including discrimination as a result of a handicap, fall under the jurisdictions of the Maryland Commission on Civil Rights, 6 Saint Paul Street, Suite 900, Baltimore, Maryland 21202, (410) 767-8600, and the U.S. Equal Employment Opportunity Commission, 131 M Street, NE, Washington, DC 20507, 1 (800) 669-4000.

5.		Filing a MOSH complaint to request an enforcement inspection of a specific safety or health problem in the workplace is NOT the same as filing a MOSH discrimination complaint.

PLEASE NOTE: A whistleblower complaint filed with MOSH cannot be filed anonymously. If MOSH proceeds with an investigation, MOSH will notify your employer of your complaint and provide the employer with an opportunity to respond.

Please complete all sections. Items noted with an asterisk (*) are required fields. Only standard keyboard characters (alphabets, numbers, and punctuation) are allowed.

Company Name *:

Company Mailing Address :

Street Address *:

City *:

State *:

Zip Code *:

+4 Ext :

Worksite Location *: Is worksite location different from Company Mailing Address?		Yes		No

Please complete worksite location address fields.

Street Address *:

City *:

State *:

Zip Code *:

+4 Ext :

Company Telephone Number * :

Ext :

Management Official in Charge *:

Management Official Phone Number and Email Address :

Description of Protected Activity *:

Please include a brief description of the safety or health condition.

Limit 1500 Characters

Description of Adverse Action *:

Limit 1000 Characters

Date of Alleged Act of Discrimination *:

Do you have a representative? *:		Yes		No

Please provide representative information.

Representative Name : First Name *:

Last Name *:

Representative Phone Number *:

Representative Email Address *:

Complainant Name : First Name *:

Last Name *:

Complainant Home or Cell Phone Number *:

Complainant Home Mailing Address :

Street Address *:

City *:

State *:

Zip Code *:

+4 Ext :

Complainant Email Address *:

Signature *:

I believe that a violation of Labor and Employment §5-604 has occurred as a result of reporting a safety or health matter in the workplace, and I am making this complaint in good faith.

This Constitutes My Electronic Signature. *

If this box is checked, this submission shall be considered as an authorized written signature.