OSHAB Appeal Form. This is a California form and can be use in General Workers Comp.
Tags: OSHAB Appeal Form, California Workers Comp, General
STATE OF CALIFORNIA Department of Industrial Relations Occupational Safety and Health Appeals Board Please mail all correspondence to: 2520 Venture Oaks Way, Suite 300 Sacramento, CA 95833 OSHAB APPEAL FORM Note: You have a total of 15 working days from receipt of a citation to file an appeal. Attach a complete copy of your citation package along with this appeal form. Failure to file a completed form may result in dismissal of the appeal. Late appeals will not be accepted unless good cause is shown. Please print legibly or type all information. A. CITATION INFORMATION Please complete the following information as indicated on your citation. 1. Case (Inspection) #: 2. Employer: 3. Employer legal name or DBA (Optional): 4. Employer contact: 5. Address: City: 6. Primary phone: ( 7. Email address: 8. Preferred method of service: ) State: Secondary phone: ( ) ZIP code: Issuance date: / / Reporting ID#: / / Date Citation Received: U.S. Postal Service OR Email (Choose one only) B. REPRESENTATIVE INFORMATION (if any) 1. Firm name: 2. Representative name: 3. Address: City: 4. Primary phone: ( 5. Email address: 6. Preferred method of service: ) State: Secondary phone: ( ) ZIP code: U.S. Postal Service OR Email (Choose one only) C. CONTACT INFORMATION and SIGNATURE I am the: Representative___ Employer___ Other___ I understand that it is my responsibility under Appeals Board regulations to notify the Appeals Board in writing if there are any changes to either employer or representative address, telephone number, and/or email address. _________________________________________________________________________________________________ Signature of employer or employer's representative Date _________________________________________________________________________________________________ Print name and title Phone No. OSHAB Appeal Form 100 (Rev. 9/16) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Employer: Case (Inspection) #: Please note that you must complete page 2 of this OSHAB Appeal Form for each citation/item. Appellant must complete a separate page 2 for each citation/item being appealed. D. APPEAL INFORMATION 1. This is an Appeal of: CITATION AND NOTIFICATION OF PENALTY CITATION No.: _____ ITEM No.: _____ NOTIFICATION OF FAILURE TO ABATE ALLEGED VIOLATION SPECIAL ORDER / ORDER TO TAKE SPECIAL ACTION 2. Specific ground(s) for this appeal are: (Check all that apply) The safety order was not violated. The classification (i.e. serious, willful, repeat) is incorrect. The abatement requirements are unreasonable: Required changes Time allowed to complete changes The proposed penalty is unreasonable. 3. An affirmative defense is a justification or excuse that if proved by appellant relieves the cited employer of all or some of the responsibility for the alleged violation. An affirmative defense must be raised by the appellant in a timely manner. Affirmative defenses for this appeal are: (Check all that apply) Independent employee action caused the violation. A different safety order applied to the work activity that is the subject of the citation, and the appellant was in compliance with that other safety order. (The different safety order should be identified.) __________________ An exception exists in the California Code of Regulations, Title 8 which allows for the action that is the subject of the citation. (The specific safety order containing the exception should be identified.) __________________ The inspection that gave rise to the citation was invalid because the Division employee who inspected the appellant's worksite failed to comply with laws governing administrative searches. Another affirmative defense: other affirmative defenses may exist and can be asserted by the employer. If the appellant contends one or more affirmative defenses exist, the appellant may, but is not required to, provide a short, plain statement in writing setting forth the facts or circumstances which, if true, would prove the affirmative defense. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ OSHAB Appeal Form 100 (Rev. 9/16) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF INDUSTRIAL RELATIONS OCCUPATIONAL SAFETY AND HEALTH APPEALS BOARD OSHAB APPEAL FORM INSTRUCTIONS AND INFORMATION How do I file an appeal? Use this form to appeal Citations and Items, Notification of Failure to Abate Alleged Violations, or Special Orders/Special Actions. Please fill out this form as completely as possible and provide all of the information requested. You must complete page 2 of this form separately for each citation and item or notification that you wish to appeal. Failure to provide the information requested could result in the dismissal of your appeal. How long do I have to complete this form and file it? An employer has 15 working days from receipt of one of the aforementioned documents for filing an appeal. An informal conference with the Division of Occupational Safety and Health about the citations issued to you will not extend the 15 working days to file an appeal. Appeals filed more than 15 working days following the employer's receipt of citations are late and will not be accepted unless good cause for filing a late appeal is demonstrated. Only the Appeals Board may grant late appeals. What other documents must be submitted with my OSHAB appeal form? Your appeal form shall be deemed incomplete unless you attach a copy of the entire citation package consisting of the following documents: (1) Citation and Notification of Penalty; (2) all of the citations and items or notifications whether you are appealing them or not; and, (3) the Notice of Proposed Penalties. Please retain the originals of these documents for future reference. Where do I file an appeal? Mail each completed appeal form and citation package as identified above to the Occupational Safety and Health Appeals Board, 2520 Venture Oaks Way, Suite 300, Sacramento, CA 95833. Please also note that you may now file your appeal online by navigating to www.dir.ca.gov/OSHAB and following the instructions provided. What happens next? When the Appeals Board receives a signed, completed appeal form, it is reviewed for timeliness and assign