Contact Information:
(505) 827-2855 MAIN // 1-800-219-6157 (toll free)
Environmental Emergencies:
505-827-9329 (24 hrs)
New Mexico
Environment Department
Occupational Health & Safety Bureau

Discrimination Complaint

By statute, in order to investigate a discrimination complaint, a signed complaint must be received in our office (or postmarked) no later than thirty (30) days after the date of the alleged retaliatory act, so please include the date of that retaliation.

Please be as thorough as possible when filling out the complaint form. When possible, include relevant dates; and the names, telephone numbers and addresses of any potential witnesses. This complaint will be investigated only if you can provide some proof that the retaliation against you was directly due to your complaints to management about health or safety issues. Specific details describing your interactions with management regarding your safety concerns will be important in a possible investigation.

Please be informed that the assigned investigator is not an attorney and cannot give any legal advice. Filing a case with the Occupational Health and Safety Bureau (OHSB) does not preclude you from seeking any other forms of relief available to you. All parties in this action have the right to retain legal counsel and a Designation of Representation form will be provided if you choose to retain counsel. Your timely cooperation is required in order to pursue this matter.

 
SECTION I: EMPLOYER
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SECTION II: DESCRIPTION OF ALLEGED VIOLATION

Describe the circumstances which led up to the action you allege constitutes discrimination. Can only contain 2-2000 characters

 
SECTION III: COMPLAINANT
State: Zip:
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SECTION IV: QUESTIONNAIRE
Is this alleged violation the subject of any Labor Union/Management grievance?
Is this alleged violation being considered by or filed with any other government agency?
       If “yes,” indicate the agency name(s) date of filing(s)
Has this alleged violation been discussed with the employer or one of his representatives?
       If “yes” indicate name of representative and title of representative
What relief is being sought?
 
SECTION V: WITNESSES (List below any witnesses who may possess information relevant to this matter)
Name Address Phone
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SECTION VI: SIGNATURE   (Type your name in the first box, then use your mouse to sign in the signature box below)

I,, affirm that this is my valid signature, and also hereby affirm that all entries contained herein are true and correct to the best of my knowledge.

Signature
Date
 
RIGHT TO DUAL FILE
Federal regulations require that our office inform you of your right to file a concurrent complaint of discrimination with Region 6 of the Federal Occupational Safety and Health Administration (OSHA). The thirty (30) day filing period that New Mexico requires also applies to federal OSHA discrimination complaints. You also have the right to request a federal review of the findings of our Bureau’s investigation, but only after you have exhausted your rights to appeal at the state level. Please designate your choice below.
 
I do not wish to file a complaint of discrimination with Region 6, federal OSHA.
I do wish to file dually with New Mexico Occupational Health and Safety Bureau (OHSB) and Region 6 federal OSHA
 
 
My signature below authorizes the NM OHSB discrimination investigator to forward a copy of my written complaint to:

11(c) Investigations
U.S. Department of Labor
Occupational Safety and Health Administration
525 Griffin Street, Room 602
Dallas, Texas 75202
(972) 850-4187

Signature
Date

Leave this empty:

 
 
 
 
 
 
 
 
 
 
 
Harold L. Runnels Building // 1190 St. Francis Drive, Suite N4050 // Santa Fe, New Mexico 87505 // tel. (800) 219-6157, (505) 827-2855

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