Form SH-6 (BWC-6605) "Complaint Form - Public Employment Risk Reduction Program" - Ohio

What Is Form SH-6 (BWC-6605)?

This is a legal form that was released by the Ohio Bureau of Workers' Compensation - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 17, 2016;
  • The latest edition provided by the Ohio Bureau of Workers' Compensation;
  • 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 fillable version of Form SH-6 (BWC-6605) by clicking the link below or browse more documents and templates provided by the Ohio Bureau of Workers' Compensation.

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Download Form SH-6 (BWC-6605) "Complaint Form - Public Employment Risk Reduction Program" - Ohio

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Public Employment
For official use only
Risk Reduction Program
State of Ohio
Division of Safety and Hygiene
13430 Yarmouth Drive
Pickerington, OH 43147
Toll Free 800-671-6858
Email: perrpcomplaint@bwc.state.oh.us
Complaint Form
Use this form to file a complaint with the Public Employment Risk Reduction Program.
The undersigned (Please check)
Employee
Employee representative
Other
believes that an occupational safety or health hazard(s) exist at the following place of employment:
Employer (City, township, school district, etc.)
Name of supervisor or manager at facility
Address
City
County
State
ZIP code
Phone
Name and title of highest administrator of public entity (director, superintendent, mayor, etc.)
Address (if different from above)
City
State
ZIP code
Phone
Does the risk pose an immediate threat of serious harm?
Yes
No
Are any employees refusing to work?
Yes
No
If yes, have employees notified the supervisor of the risks?
Yes
No
What was the result?
Have employees contacted the Public Employment Risk Reduction Program regarding this hazard?
Yes
No
When?
Staff member contacted
Nature of hazardous activity
1. Describe the existing hazards, including the number of employees exposed to the danger.
(Additional comments may be made on reverse side)
BWC-6605 (Rev. Nov. 17, 2016)
Page 1 of 2
SH-6
Public Employment
For official use only
Risk Reduction Program
State of Ohio
Division of Safety and Hygiene
13430 Yarmouth Drive
Pickerington, OH 43147
Toll Free 800-671-6858
Email: perrpcomplaint@bwc.state.oh.us
Complaint Form
Use this form to file a complaint with the Public Employment Risk Reduction Program.
The undersigned (Please check)
Employee
Employee representative
Other
believes that an occupational safety or health hazard(s) exist at the following place of employment:
Employer (City, township, school district, etc.)
Name of supervisor or manager at facility
Address
City
County
State
ZIP code
Phone
Name and title of highest administrator of public entity (director, superintendent, mayor, etc.)
Address (if different from above)
City
State
ZIP code
Phone
Does the risk pose an immediate threat of serious harm?
Yes
No
Are any employees refusing to work?
Yes
No
If yes, have employees notified the supervisor of the risks?
Yes
No
What was the result?
Have employees contacted the Public Employment Risk Reduction Program regarding this hazard?
Yes
No
When?
Staff member contacted
Nature of hazardous activity
1. Describe the existing hazards, including the number of employees exposed to the danger.
(Additional comments may be made on reverse side)
BWC-6605 (Rev. Nov. 17, 2016)
Page 1 of 2
SH-6
2. Symptoms or injuries suffered by employees as a result of the risk.
3. List by number and/or by name the occupational safety and health standard(s) violated, if known.
4. Specify the particular building or work site where the risk is located, including full address.
5. To your knowledge, how long has the risk existed within the workplace?
6. Have employees notified supervisors of the risk?
Yes
No
If so, give results, including any steps taken to correct the problem.
7. Additional comments.
Name of individual filing complaint
Signature
(please print)
By statute, you must sign this form for the administrator to investigate the problem.
We keep the identity of the complainant confidential.
We will send a copy of the notification letter we sent to the employer to the complainant at address below.
Address
City
State
ZIP code
Phone
Email address
The Public Employment Risk Reduction Program established by Ohio House Bill 308 provides the following: Any
public employee or public employee representative who believes that a violation of an occupational safety or
health standard exists that threatens physical harm, or that an imminent danger exists, may request an inspection
by giving notice to the administrator’s designee of the Public Employment Risk Reduction Program, or an autho-
rized representative, of such violation or danger. Any such notice shall be reduced to writing, shall set forth within
reasonable particularity the grounds for the notice, and must be signed by the employee or employee representa-
tive. Within seven days of the receipt of the complaint notice, the administrator’s designee must submit a letter of
notification to the public employer, sent by certified mail, which outlines the allegations of the complaint. This letter
of notification will not include the name(s) of the complainant(s). The public employer must then, within thirty days,
respond back to the administrator’s designee regarding the allegations. If the employer does not respond, or if the
administrator’s designee determines that the response is inadequate, an investigation of the alleged conditions will
result. If the administrator’s designee, or an authorized representative, determines that there are no reasonable
grounds to believe that a violation or danger exists, he shall notify the employee or representative of the employee
in writing of such determination.
BWC-6605 (Rev. Nov. 17, 2016)
SH-6
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