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 800-892-2674 or the St. Louis office at 800-392-7743.

Date
10/16/2021

Complainant Information
 

Employer Information
 

 
 

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
 
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.



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.