Form MIOSHA-GI-516 "Miosha Discrimination Complaint Form" - Michigan

What Is Form MIOSHA-GI-516?

This is a legal form that was released by the Michigan Department of Licensing and Regulatory Affairs - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the Michigan Department of Licensing and Regulatory Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MIOSHA-GI-516 by clicking the link below or browse more documents and templates provided by the Michigan Department of Licensing and Regulatory Affairs.

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Download Form MIOSHA-GI-516 "Miosha Discrimination Complaint Form" - Michigan

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Michigan Department of Licensing and Regulatory Affairs
Michigan Occupational Safety & Health Administration
MIOSHA DISCRIMINATION COMPLAINT FORM
Complainant:*
Date of Hire:*
Job Title and Department:*
Case No. (office use only)
Address:*
City:*
State:*
Zip Code:*
Telephone No.*
Present Status:*
Still Employed
Laid Off
Discharged
Suspended days
Employer :*
Address:
Telephone No:*
County:
City:
State:
Zip Code:
No. of Employees*
Average Hours Worked:*
Rate of Pay:*
Supervisor or Contact Person:*
Union & Local #
If so, date your grievance was filed:
Union:*
Have you filed a grievance:
Yes
No
Yes
No
Did you file a complaint of safety or
Date you filed complaint:
If you filed a complaint with MIOSHA
Was your name revealed to employer?
health?*
was it?
Yes
No
General Industry
Construction
Yes
No
Date and time discrimination occurred:*
Why do you think you were discriminated against?*
Did you verbally complain of alleged
To whom, when and what were the results of your complaint:
unsafe/unhealthy conditions to employer:
Yes
No
Summary of Events:* (add additional sheets if necessary)
FOR OFFICE USE ONLY:
Date:
TYPE OF BUSINESS
NAICS CODE
Person who took complaint:
Investigator assigned to:
*Information Required to Complete Form
Return completed form to:
EMPLOYEE DISCRIMINATION SECTION
CADILLAC PLACE  3026 W. GRAND BLVD.  SUITE 9-450  DETROIT, MICHIGAN 48202
www.michigan.gov/miosha  (313) 456-3109  (313) 456-4226 FAX
MIOSHA-GI-516 (11/2017)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin,
color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you
may make your needs known to this agency.
Michigan Department of Licensing and Regulatory Affairs
Michigan Occupational Safety & Health Administration
MIOSHA DISCRIMINATION COMPLAINT FORM
Complainant:*
Date of Hire:*
Job Title and Department:*
Case No. (office use only)
Address:*
City:*
State:*
Zip Code:*
Telephone No.*
Present Status:*
Still Employed
Laid Off
Discharged
Suspended days
Employer :*
Address:
Telephone No:*
County:
City:
State:
Zip Code:
No. of Employees*
Average Hours Worked:*
Rate of Pay:*
Supervisor or Contact Person:*
Union & Local #
If so, date your grievance was filed:
Union:*
Have you filed a grievance:
Yes
No
Yes
No
Did you file a complaint of safety or
Date you filed complaint:
If you filed a complaint with MIOSHA
Was your name revealed to employer?
health?*
was it?
Yes
No
General Industry
Construction
Yes
No
Date and time discrimination occurred:*
Why do you think you were discriminated against?*
Did you verbally complain of alleged
To whom, when and what were the results of your complaint:
unsafe/unhealthy conditions to employer:
Yes
No
Summary of Events:* (add additional sheets if necessary)
FOR OFFICE USE ONLY:
Date:
TYPE OF BUSINESS
NAICS CODE
Person who took complaint:
Investigator assigned to:
*Information Required to Complete Form
Return completed form to:
EMPLOYEE DISCRIMINATION SECTION
CADILLAC PLACE  3026 W. GRAND BLVD.  SUITE 9-450  DETROIT, MICHIGAN 48202
www.michigan.gov/miosha  (313) 456-3109  (313) 456-4226 FAX
MIOSHA-GI-516 (11/2017)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin,
color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you
may make your needs known to this agency.