Work Hazard Complaint Form-OR

Governor Brown has begun to ease the restriction on non-urgent care. Any hospital, clinic, or dental facility that chooses to resume non-urgent care has been encouraged to move slowly and must demonstrate that they have the ability to support workers in safely resuming care, minimize the risk of coronavirus transmission to patients and workers, and maintain adequate facility capacity in the event of a surge in COVID-19 cases.

Working in a Site Reopening:

In order to resume non-urgent care safely, our hospitals must provide us with the PPE needed to protect us and our patients. If you are working and believe the safety of your patients, your coworkers, or your own is at risk as a result of inadequate Personal Protective Equipment (PPE), take action by filling out the complaint form below which will be sent to the Oregon Occupational Safety and Health Administration.

Working in a COVID Unit:

For those of us in designated COVID units or working with COVID patients, our hospitals must demonstrate that they have an adequate amount of PPE available as outlined by the CDC guidance for the extended use or reuse of PPE. Extended use refers to wearing the same respiratory or eye protection for repeated encounters with several different patients with the same infectious disease diagnosis without removing between encounters.

CDC guidance for the extended use or reuse of PPE:

• Minimize the number of individuals who need to use respiratory protection through the preferential use of engineering and administrative controls
• Use alternatives to N95 respirators (e.g., other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air purifying respirators, powered air purifying respirators) where feasible;
• Implement practices allowing extended use and/or limited reuse of N95 respirators, when acceptable; and
• Prioritize the use of N95 respirators for those personnel at the highest risk of contracting or experiencing complications of infection.

If you believe the safety of your patients, your coworkers, or your own is at risk as a result of inadequate Personal Protective Equipment (PPE),take action by filing the complaint form below which will be sent to the Oregon Occupational Safety and Health Administration.

Employer's Name *

Type of Business *

Employer's Address *

City *

State *

Zipcode (5 digits) *

County *

Telephone *

Employer's Email Address

Where can OSHA contact an employer representative

Contact Person First Name

Contact Person Last name

Description of Hazard *

Location of the Hazard *

Street address and where at the address is the hazard (room, building, etc)

This was Reported to (may select more than one option) *

My Supervisor The Safety Committee A coworker I haven't reported the hazard to anyone

If you select "Yes" to the question, "keep your identity confidential," the information below will not be provided to the employer.

Do you want to keep your identity cofidential *

Yes No

Which of the following describes you? *

We can't contact you or keep you informed unless you provide the following information.

First Name

Last Name

Your Email Address

Retype Email Address

Telephone

Mailing Address

City

State

Zipcode (5 digits)