An employee may use this form to file a discrimination complaint if the employee believes the employer has retaliated against the employee for exercising employee rights under the Arizona Occupational Safety and Health Act. Submission of this form constitutes filing a discrimination complaint pursuant to Arizona Revised Statutes (A.R.S.) section 23-425.

It is not necessary to use this form. ADOSH will accept a discrimination complaint made orally (telephone or walk-in) or in writing, and in any language. An employee may also file a complaint or obtain more information by contacting ADOSH Discrimination Investigations at 602-542-5355 or by contacting ADOSH toll free at (855) 268-5251.

This form must include an accurate description of each allegation of retaliation (what happened). The description should include specific evidence supporting the allegation.  IMPORTANT: the information contained in this complaint will be shared with the employer including the complainant’s identity. A whistleblower complaint filed with ADOSH cannot be filed anonymously.

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