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.