Get Da Form 4755
And is not intended to constitute the exclusive means by which a complaint may be registered with the local Safety Office (Ref OSHA Poster on rights of employees and their representatives). The undersigned (check one) Employee Representative of employees Other (Specify) believes that a job safety or health hazard exists at the following place of employment Does this hazard(s) immediately threaten serious physical harm? If "yes" checked, immediately contact your supervisor or safety represe.
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