Request for Safety and Health Inspection of Employing Office Form 1341

• Legal Form Number: 1341
• Section: Office of Congressional Workplace Rights (United States)

OFFICE OF CONGRESSIONAL WORKPLACE RIGHTS

OFFICE OF THE GENERAL COUNSEL

Request for Safe ty and Health Inspection of Employing Office

OCWR FORM 1341

VERSION 2019.03 Page 1

DO NOT WRITE IN THIS SPACE

Case No.

Date Filed

I am an employee or a representative of an employing office in the Legislative Branch.

I am requesting this inspection because I believe that a safety or health hazard exists in the workplace.

I wish to do not wish to remain anonymous.

IF YOU WISH TO REMAIN ANONYMOUS, YOUR NAME WILL NOT BE REVEALED TO OTHERS UNLESS YOU TELL US OTHERWISE.

Description of the hazard. Desc ribe the unsafe acts and/or hazardous conditions and any injuries, illnesses, or “close

calls” caused by these acts or conditions.

INCLUDE DETAILS SUCH AS DATES AND LOCATIONS. ADDITIONAL OR SUPPORTING INFORMATION MAY BE ATTACHED.

Does the hazard described above continue to occur? Yes No I don’t know

If it continues, how often does it occur? Continually Daily Weekly Monthly

Other frequency

Room LA 200, Adams Building • 110 Second Street, SE • Washington, DC 20540-1999 • t/202.724.9250 • f/202.426.1663 • tdd/202.426.1912

www.ocwr.gov