Missouri Labor | WSC Form

Workplace Safety Complaint Form

Chapter 292, RSMo

For more information about free workplace safety program, visit www.labor.mo.gov/SAFE

* = Required

To mail, print this form and send to:

Division of Labor Standards

Attn: Workplace Safety Program

P.O. Box 449, Jefferson City, MO 65102-0449

Phone: 573-751-3403 Fax: 573-751-3721

Email: workplacesafety@labor.mo.gov

When using this form, please use one of the following web browsers: Microsoft Edge, Google Chrome, or Mozilla Firefox.

If you are an employee within the public sector and are concerned about safety and health conditions at your facility, please complete and submit the following form. If you are an employee within the private sector, the Occupational Safety and Health Administration (OSHA) has jurisdiction over your issue. You may contact OSHA at the Kansas City office at (816) 483-9531 or the St. Louis office at (314) 425-4249.

Date
04/19/2024

Complainant Information

First Name

Last Name

Suffix

Address

City

State

Zip Code

Zip + 4

Phone

Alt. Phone

Confirm Email

Employer Information

Name of Employer

Employer Address

Employer City

State

Zip Code

Zip + 4

Employer Phone Number

Alt. Phone

Employer Website

Additional Information - Supporting Documentation

Attachments must not exceed 20 MB and must be one of the following types: .doc, .docx, .xls, .xlsx, .txt, .jpg, .jpeg, or .png

Photo/pics of proj/worked performed

Other Information

If you are unable to attach the documentation electronically, please indicate below in the "Summary of Complaint" a brief description of documentation you have. An investigator may contact you and ask to have it mailed or faxed to our agency if the documentation is needed.

Summary of Complaint

By entering my name and submitting this electronically, I do hereby affirm, under penalties of perjury, that the above-stated information is true and correct to the best of my knowledge, information, and belief.

First Name

Last Name

Division of Labor StandardsWorkplace Safety Complaint Form

Workplace Safety Complaint Form

Division of Labor Standards
Workplace Safety Complaint Form