United States Department of Veterans Affairs

Request for Inspection

Complaint - Request for Workplace Inspection

This is a web version of the form VA2169


Request for Inspection of Workplace

Instruction to Employee: If you believe an unsafe or unhealthful condition exists in any workplace in which you are employed, you may use this form to request an inspection. If you believe an immediate danger exists you may use a telephone (OSHA's work refusal position). However, before you requested assistance through this form you are first requested to work through your facility safety and health program officials and then contact your agency's next program level (e.g., VISN safety/health official), as described on the Safety Poster (form VA2180). This poster is posted at the facility where you work with important telephone numbers. If you are not satisfied with the VA's disposition of your concern you may contact OSHA - note OSHA will ask if you contacted your employer and who with your concern. The facility safety committee is a valuable organization to raise safety and health concerns.

Employee responsibilities under OSHA and Employer responsibilities under OSHA.

Please fill out sections 1 through 18.

Items in red must be completed in order to accept your submission. 

 

1. Name of Facility: 
NOTE: In order to fully process your request, complete and accurate information about the worksite is necessary.
2. Site Street: 
3. Site City: 
4. Site State  
5. Site ZIP Code: 
6. County:
7. Mailing Address (if different): 
8. Management Official: 
9. Telephone Number: 
10. Facility Type (e.g., clinic, hospital, VBA Office): 
11. Hazard Description. Describe briefly the hazards(s) and/or standards (e.g., OSHA, JCAHO, VA, etc.) which you believe exist. Include the approximate number of employees exposed to or threatened by each hazard and whether the condition has been responsible for an accident, injury, or occupational illness:  

12. Hazard Location. Specify the particular building or worksite where there may be an hazard:  


13. This condition has been brought to the attention of: (Choose all that apply)

  • Facility Management (specify)  
  • Agency Official, e.g, VISN (specify)
    Headquarters Official (specify)

    Other Government Agency (specify)

14. I am a(n): 


OPTIONAL

You have the right to request that your name not be revealed. Providing your name and address, will allow us to communicate with you regarding your concern.

15. Please indicate your desire: 

  • Do NOT reveal my name to my Employer
    My name may be revealed to my Employer

16. Your Name: 
17. Your Telephone Number: 
18. Your Mailing Address (Street, City, State, Zip):
19. Your E-Mail Address:  


20. If you are an authorized representative of employees affected by this hazard, please state the name of the organization that you represent and your title:
Organization Name:  
Your Title: