ࡱ> qsp% &bjbj%% GGl$<P4< h....E=$a$! #u@E=..p === ..==4=qq. ®<F qqd 0 q$($q=<< Notice of Alleged Occupational Safety and Health Hazards Instructions/Handling For the General Public: The Department of Labor and Economic Growth has developed this NOTICE in order to promptly and efficiently investigate the nature and extent of the conditions, that you feel are creating a hazard to safety or health or otherwise violate Michigans Occupational Safety and Health Act Standards. This NOTICE is not intended to constitute the exclusive means by which a complaint may be filed. Section 28(1) of Michigans Occupational Safety and Health Act (Act 154, P.A. 1974) describes the procedures by which complaints may be filed and the actions that will be taken by the Department. An employee or employee representative who believes that a violation of a safety or health standard exists that threatens physical harm to an employee, or that an imminent danger exists, may request an inspection by giving written notice of the condition to the department. The notice shall be reduced to writing, and shall set forth with reasonable detail the grounds for the complaint. Upon receipt of a complaint and if the department determines there are reasonable grounds for the complaint, the department shall conduct an inspection. A copy of the complaint shall be provided to the employer or his agent not later than at the time of the inspection. Upon the request of the person giving the notice, his or her name and the names of employees referred to therein shall not appear in the copy or on the record which is published, released, or made available. If the department determines that there are no reasonable grounds to believe that an inspection should be conducted, it shall notify, in writing, the complainant of its determination. Sections 65(1) and (2) make it unlawful for an employer to discharge or in any manner discriminate against an employee for filing a complaint with the Department or exercising any other rights provided by the act. Any employee who believes that they have been discharged or otherwise discriminated against by a person in violation of this section may file a complaint with the department alleging the discrimination within 30 days after the violation occurs. INSTRUCTIONS: Complete the form as accurately as possible. Describe each hazard you think exists in as much detail as you can. If the hazards described in your complaint are not all in the same area, please identify where each hazard can be found at the worksite. If there is any particular evidence that supports your suspicion that a hazard exists (for instance, a recent accident or physical symptoms of employees at your site), include the information in your description. If you need more space than is provided on the form, continue on another sheet of paper and attach. If your complaint issues are mostly related to construction safety or health, return or fax the completed form to:  FORMCHECKBOX  Michigan Department of Labor & Economic Growth Michigan Occupational Safety and Health Administration (MIOSHA) Construction Safety and Health Division P.O. Box 30645 Lansing, MI 48909-8145 TELEPHONE: (517) 322-1856 (517) 322-6354 (FAX) If your complaint issues are mostly related to general industry safety or health, return or fax the completed form to:  FORMCHECKBOX  Michigan Department of Labor & Economic Growth Michigan Occupational Safety and Health Administration (MIOSHA) General Industry Safety and Health Division P.O. Box 30644 Lansing, MI 48909-8144 TELEPHONE: (517) 322-1831 (517) 322-6353 (FAX) NOTE: It is unlawful to make any false statement, representation or certification in any document filed pursuant to the Michigan Occupational Safety and Health Act of 1974, as amended. Violations can be punished by a fine of not more than $10,000, or by imprisonment of not more than six months, or by both (Section 35(7)). MIOSHA-7 (04/04) Michigan Department of Labor and Economic Growth Michigan Occupational Safety and Health Administration HYPERLINK "http://www.michigan.gov/cis"www.michigan.gov/dleg  FORMCHECKBOX  General Industry Safety and Health  FORMCHECKBOX  Construction Safety and Health NOTICE OF ALLEGED SAFETY OR HEALTH HAZARDS Complaint Number FORMTEXT      ESTABLISHMENT NAME  GOTOBUTTON  FORMTEXT      Site Address (Street, City, State, ZIP) GOTOBUTTON  FORMTEXT      Site Phone FORMTEXT      Site FAX FORMTEXT      Mailing Address (if different from Site) FORMTEXT      Mail Phone FORMTEXT      Mail FAX FORMTEXT      Management Official FORMTEXT      Telephone FORMTEXT      Type of Business FORMTEXT      HAZARD DESCRIPTION/LOCATION. Describe briefly the hazards you believe exist. Include the approximate number of employees exposed to or threatened by each hazard. Specify the particular building or worksite where the alleged violation exists. FORMTEXT      Has this condition been brought to the attention of: FORMCHECKBOX  employer  FORMCHECKBOX  other government agency (specify)  FORMTEXT      Please indicate your desire: FORMCHECKBOX  do NOT reveal my name to the employer  FORMCHECKBOX  I want my name revealed to the employerThe undersigned believes that a violation of an occupational safety or health standard exists which is a job safety or health hazard at the establishment named on this form.Check ONE box.  FORMCHECKBOX  current employee  FORMCHECKBOX  federal safety and health committee  FORMCHECKBOX  representative of employees  FORMCHECKBOX  other (specify): FORMTEXT        FORMCHECKBOX  former employee, last date worked: month:  FORMTEXT       day:  FORMTEXT      year:  FORMTEXT     Complainant Name: FORMTEXT      Telephone: FORMTEXT      Address (Street, City, State, ZIP): FORMTEXT      Signature:Date: FORMTEXT      If you are an authorized representative of employees affected by this complaint, please state the name of the organization that you represent and your title.Organization Name:  FORMTEXT       Your Title:  FORMTEXT       MIOSHA-7 (rev. 04/04)The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.Completion: Voluntary MIOSHA-7a (04/04) TUmn | ;cdrst2S{|JK   /\mnx갺jCJUjCJU0JCJjCJU jCJUjtCJUjCJU jCJU>*CJ>*CJCJCJCJ 5CJ\jCJUmHnHu9TUmn c b h h$ a$$(d)fRSa$$(d)fRSa$ $a$&&byz{8Opq (d)fRS$a$$ a$  h hK./Z[\m  $If] $a$ (d)fRS xy  468:RTVjlnxz~,.BDFPRfh|~$&:޹ޯޥޛjCJUjICJUjCJUjaCJUCJ 5CJ\jCJU jUCJCJjCJUmHnHu jCJUjyCJU:8|jdZ  $If] $If$$IfTl4 F")  0)6    4 la|~,}ww$If$If|$$IfTl4 0 )   0)64 la,Tf}}}}}$If|$$IfTl4 0 )   0)64 la 8222$If$$IfTl4 r T)   (0)64 la  $L^}}}}}$If|$$IfTl4 0 )   0)64 la:<>HJL^`tvx8:NPR\^bHLNbdfprtv <޶޳ީާޠޠjCJU jCJU>*jyCJUCJjCJUjCJUjCJUjCJUCJjCJUmHnHu jCJUj1CJU782222$If$$IfTl4 r T)   (0)64 la8`QKK$If$$IfTl4 \ )  0)64 la`bJ}$If|$$IfTl4 0 )    0)64 laJLtvT,t&$If`$$IfTl4:))0)64 la &$If^&i$$IfTl4))   0)64 laZz@~$$IfTl4C0)0  0)64 la$If<>@  Z\xz|#$%FGUVWhisʶʬʢʘʎ녁>*CJj>*CJUj CJUj# CJUj CJUj7 CJUj CJUjM CJUCJjCJUmHnHujCJU jCJUCJ jCJUjcCJU/ !dz^TTT  $If  $(d)fIfRS$If~$$IfTl4L0)0  0)64 last   , . 0 !! !!!!!!R!T!V!`!b!z!|!!!!!!!!!!ڿڵڿڞڿڔڿڊڿڀڿjCJUj]CJUj CJUjq CJUjCJUmHnHuj CJU jCJUj CJUCJ jCJUCJj>*CJUmHnHuj>*CJUj >*CJU2!!1IDATH 1h$vw (}DWю$_㙕tw`F+P,¹r_ENK"ؤJ.NҸOj Dކͽ<IV6}$Ҋ0abˢeIkNEl%?oVIs9ZoɓXf[blb"W"oڏDMFaɬ]+`$٢F&k!-l/y#ƫY\"Y1:0K| *l˻on%.Ξ$:fom4JdѶlޕNuEݏ\Z+u|,?kZK>J4$LpadNܖ͏C.G'B?~ՄvP'Ơk 5O76`Qvޗ|ސ]>#NMࣛ"寔+qoouo 7+p`ea`f='!Rw(U᧽O~#"0%@6-xg~{ASsᷛDYДkk)+`4M>mVǹ{JfJg9=Qh\+S݉]S3P@{Z#:#w&b ͚NM#V;mz&l;uV@r{۠25nMƳYf/|7W91&ɽ4Ԑv MN<ˊiy;Zebɛy Nivj<lŬ=>GrˎWnK\ IENDB`nl6wZE}:PNG  IHDRi{@B^PLTEcccc1ccccc1Bsν1c111c1ccBBBcc!!!c1c1Μcc!R11c1ΜΜc1111c11111sssc111c1cc!1RRRc1c1c1c1!Μ1cccc1c1ccc11cΜBR111c111cRcc1c1c111Μ11c11Bc1cΜ111Μc1cc1c1cΜ11ccc1c1cΜccc1c1ca*tRNS@fbKGDH cmPPJCmp0712HsIDAThCZ_vH`,,b侀Tpdz)Iomv]Y;7۲y$ IslYy?yt$t R?}24M͐(<;555' ~'WYM[$?#_4mK%t|øUʹ4B-[~Enײ 4]xSzmM/1)o̔;FJjT]T7"%\eMiZҪSeWXOBx蓗0]{ P *}-ʑ&c;rRNV|Stt; iATq|7R޺Qd}w䛪r`كr#ɞ8eκiբuW#P5T@nyJ24̊ b$#kq E [5ڃ7%38gJxl` 8 6JaA _P^5;+Kv˲_}nӎ3V*bɄ A $WF68N"Q[ +n NF$N.Nt1JP.B*O~k|;h6}ڎ7|EZZ+!T9^',XnU+3 =q%irـp ϝC3)B ֫ Ll"3Y*8mzZ\@` 0דO` Ѥ9l{-6 !G b\a`sH A$ nc98iX3Ҥp+MrBᰗ;!{ !?Yƫ[TDqc(XX.,#/6 ȱnh=l2{̾n2H$狢J+<7|Ӈp٭!Bu9SQ,QCl쿵 ~g Lwh 8|) xrr<%)&sΠ'䊹\n{n-K}hܮ O{DXˤW-)P׿n%Q|㷯M=c iܳPA pQ‰?{yD0Kі6vo@XxI \qA|K>.)g}3u<`(̓;MX8 '23g8w`cIt.S>\oቐ rAp&ieU63~m/} ,P"oǍJ8'`{`mnoo:ƗÞ2yHF}!/WݻJN{<`~_?*d[UUD}Ӌ+IP챉 ?Bp~p=`sc0;):dk_WX.[GXESnꏞ;fe~}#.%&%UmudC-Zy'w U ^)5 ;L#9~@Iu]D̶i-NqG ٖ3lοR9b7wl QwP/*x`~!aJÑ~m2@I[ NsmXE]*n?u:Nnv6g KgiaCEp5[bXQAIAAڕi8KyeV#_5 "Y2FL7y+P՟A?ɏo7iǓIn֏7Nƥ7pdK)44f, }neXtNAG=?=OuH/spZ. waϤͫaJ88L'if֏ɱzpك{(bnָ#;"6Rfs<$}4XOza)@ƴ6Q{8H0Pl{"XœLhK0f|{j5q %"F'/!-2l\ƲpqJNFĸ Ǿ2H,ձ!V=r߹pb,c^ , `PL{4{.  g?]=xV ÄCLoc N-dsW9D ?Lro,.A`gqG@"S&u¶i?;, ~W覄E  U)(zaA-A~@ * C,-0A2f,5D&U15E T8 xx;xPCUXU64eEu1"gѬs n0ҁ/iˋ%FZa(6nZՏ*z'x6$Ъ43aOB=2x^)hefR2547<%jV#Cd|1m՗vk KKh0#f:ZVtZhW+U_lĉ9l1#&ncQ<~:eːM'ҙ9,`> Ц/4BA9x.5H<f`؉27+0Z V X-WbzD32$ɾlbs Ks:f mTir i?%>=H%c 2kzJooGw2O2t kgܐLLPVRM1${gDq_=_cw@"^f,A QO ݛǔ<2HӰPz2as-1ZW/w#Vίd.AL|#pY] {q55|]\FЗRx^Jpg:WY1luiviir7#n]U-20bL|n=SMk}Pл <82- ^w@Kg?/ GXa{9/LW,_&U% tY#+8e5d:9u6o ΖzC[\V$rTĵJHfI+G*B* phff>V@> FollowedHyperlink >*B*phff3JYJ Document Map-D M OJQJ^JTB@"T Body Text, (d)fRSCJXP@2X Body Text 2, (d)fRSCJ,B, Header  !, R, Footer  !<Q@b< Body Text 3$ a$CJh*hTUmn c b y   z { 8OpqK./Z[\m$-ABRk*+ 45\j'abz{  !   0@0@0@0@0@00@0@0@0@0@0@0@0@0@00000@0@0@0@0@0@00@0000@0@0@0@0@0@00@0@00`0000000@0h@0@0/@0/@0/0/0/@0/0/@0/@0/@0/0/@0/@0/@0/0/@0/0/0/@0/@0/0/@0/@0/@0/0/@0/0/0/@0/0/@0/0/@0/@0/0/@0/@0/@0/0/0/@0/@0/0/@0/@0/0/0/@0/@0/@0/0/0/0/@0/@0/0/@0/0/@0/@0/0/@0/@0/@0/@0/0/@0/@0/@0/0/0/0/@0/0/0/0/@0/@0/@0/@0/0/x:<s!&"(*-b| `J!!"b"#2$&&& !#$%&')+,./0123&c s {  my"-9?kw}"( ,2jz'7/Xh4@FMY^gsx G$G$XG$G$F2F2FFFFFFFFFFG$G$FG$G$G$G G$G FG$FFFFFFFFF/Xb$'E *# @Th b$6wZE}:t o @.H(    s Al ? 0http://www.geobop.com/World/NA/US/1Images/Arms/MI.gifMIArms.gif (6456 bytes)"  s Al ? 0http://www.geobop.com/World/NA/US/1Images/Arms/MI.gifMIArms.gif (6456 bytes)"  Al ?C:\DOCUME~1\kbengh\LOCALS~1\Temp\162.tmp\postextb.gif%)t%)t$Check1Check2Check4Check5Text1Text2Text3Text4Text5Text6Text7Text8Text9Text10Text11Text12Check7Check8Text16Check9Check10Check11Check16Check12Check17Text13Check13Text14Text15Text17Text18Text19Text20Text21Text24Text23d | n.l!k( Y5Nh   !"#t  #@~)3{80iG_yy3$/Consumer & Industry Services&L:\internet\wsh\CIS_WSH_complaint1.dotConsumer & Industry Services5L:\internet\wsh\compliance\CIS_WSH_complaint_form.dot.[\m$-ABk*+ 45jabz{  !   @& pzzzz@<@ "$L@UnknownG: Times New Roman5Symbol3& : Arial5& z!Tahoma"XhR&R&Ck .!20d2Q5Michigan Department of Consumer and Industry ServicesConsumer & Industry ServicesConsumer & Industry ServicesOh+'0 ,P x    6Michigan Department of Consumer and Industry ServicesumichConsumer & Industry Serviceser onsonsCIS_WSH_complaint_form.dotsConsumer & Industry Serviceser 2nsMicrosoft Word 9.0 @@L R@fu@fu՜.+,D՜.+,p, hp  State of Michigantm.  6Michigan Department of Consumer and Industry Services Title(X` _PID_HLINKSMicrosoft ThemeAP**http://www.michigan.gov/cis\6http://www.geobop.com/World/NA/US/1Images/Arms/MI.gif\6http://www.geobop.com/World/NA/US/1Images/Arms/MI.gif6C:\DOCUME~1\kbengh\LOCALS~1\Temp\162.tmp\postextb.gif pstmdrn 011  !"#$%&'()*+,-./0123456789:;<=>?@ABCEFGHIJKLNOPQRSTUVWXYZ[\]^_abcdefgijklmnorRoot Entry F'ǮtData D!1TableM$WordDocumentSummaryInformation(`DocumentSummaryInformation8hCompObjjObjectPool'Ǯ'Ǯ  FMicrosoft Word Document MSWordDocWord.Document.89q