Report Jobplace Discrimination Jobplace Discrimination Complaint Establishment Name*Site Physical Address*Street AddressAddress Line 2CityZIP CodeMailing Address (If different)Street AddressAddress Line 2CityZIP CodeManagement OfficialFirstLastPhoneType of BusinessDiscrimination Description* Describe briefly the discrimination which you believe exist. Include the approximate number of employees exposed to or threatened by discrimination. Discrimination Location*Specify the particular building or worksite where the alleged violation existsThis condition has been brought to the attention of: (Choose all that apply)EmployerGovernment AgencyI am a(n):EmployeeRepresentative of EmployeesPlease indicate your desire:The VOSHA Act gives complainants the right to request that their names not be revealed to their employer. Providing your name and address will only allow VOSHA staff to communicate with you regarding your complaint.Do NOT reveal my name to my EmployerMy name may be revealed to my EmployerComplainant name*FirstLastComplainant email address*Complainant Telephone Number*Complainant Mailing Address*Street AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodeIf you are an authorized representative of employees affected by this complaint, please state the name of the organization that you represent and your titleOrganization NameYour title