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Maine Department of Labor
Bureau of Labor Standards
Workplace Safety and Health Division
State House Station #45
Augusta, Maine 04333-0045
Telephone (207) 623-7900
TTY (800) 794-1110
Fax (207) 623-7938
Public Sector Employee Complaint FormDownload this form, complete it, then mail or fax it to address above. If you have any questions about filing a complaint or completing this form, call 207-623-7900.
Complaint # ________
Please check one: Employee q Employee Rep. q General Public q Other:
Believes that a violation of an occupational safety and health standard threatens physical harm, exists at the location indicated below.
Name of Accused:
Location of alleged violation(s):
Does the alleged violation(s) immediately threaten serious harm or death?
YES q NO q
Has the condition(s) been discussed with the employer and no action taken?
YES q NO q
Who did you discuss this with?
Describe the alleged violation(s):
PLEASE USE REVERSE SIDE FOR ADDITIONAL COMMENTS
Please check one: DO NOT reveal my name q My name may be used q
Name of Complainant:
City/Town: Zip Code:
Telephone where you may be called?
BLS form 712