Employment Status

Which best describes you:

Contact Information
more items

Contact Address

Job Information

Final Wage Period Weight

Representative Information

Union Information

Are you represented by a union?
Basic Union Information

Union Address Information

Employer Information

Employer Address Information

Worksite Address
Mailing Address

Allegation Information

Type of Retaliation

Reasons for Action Taken

Have you filed a previous complaint or complaints against the employer?
The organization you filed a complaint with.

Other Actions

Have you taken any other actions to appeal, file a grievance or report this?
Name, Agency, etc.

Comments

Signature

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