Date:

Maine Department of Labor
Bureau of Labor Standards
Workplace Safety and Health Division
State House Station #45
Augusta, Maine 04333-0045
Telephone (207) 624-6400
TTY (800) 794-1110
Fax (207) 624-6449

Public Sector Employee Complaint Form

Download 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 207-624-6400.

Complaint # ________
(Office Use Only)

Date:

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:

Address:

City/ Town:

Zip Code:

Telephone:

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?
Name:
Title:

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:

Address:

City/Town: Zip Code:

Telephone where you may be called?

BLS form 712