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OSHA Whistleblower Complaint

OSHA Section 11(c) Whistleblower Complaint

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Template

WHISTLEBLOWER COMPLAINT UNDER SECTION 11(c) OF THE OSH ACT

COMPLAINANT:
{employee_name}
{address}
{phone} | {email}

EMPLOYER:
{employer_name}
{employer_address}

1. PROTECTED ACTIVITY:
   Date(s): {protected_activity_dates}
   Description: {protected_activity}

2. ADVERSE ACTION:
   Date(s): {adverse_action_dates}
   Description: {adverse_action}

3. KNOWLEDGE:
   How did the employer know about your protected activity?
   {employer_knowledge}

4. TEMPORAL PROXIMITY:
   Time between protected activity and adverse action: {time_gap}

5. EVIDENCE:
   {evidence}

6. WITNESSES:
   {witnesses}

7. RELIEF SOUGHT:
   {requested_relief}

IMPORTANT: This complaint must be filed within 30 days of the adverse action.

Signature: ___________________
Date: {date}

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