Whistleblower Retaliation Complaint Form

Whistleblower Retaliation Complaint Form
Please Note:

This form is for Public Sector Employees only. Public Sector Employees include those of state agencies, quasi-public agencies, municipal governments, and local and regional boards of education. If you believe that you are a victim of retaliation for exercising your rights under the CONN-OSHA statutes, you may file a complaint using this form. CONN-OSHA only has jurisdiction over public sector employers in Connecticut, excluding the Federal Government. Please visit the United States Department of Labor OSHA website to file a complaint against all other employers. While those complaints must be filed within 30 days of the last adverse action, CONN-OSHA retaliation complaints must be filed within 180 days of the last adverse action.

"*" indicates a required field.
Have you suffered an adverse employment action? (One selection is required) To have a valid complaint, you must allege that your employer took at least one adverse employment action against you. An action is "adverse" if it negatively affected your conditions of employment in any way (see examples below). If yes, please select your most recent adverse employment action:*

Termination / LayoffDisciplineDemotion / Reduced HoursSuspensionDenial of BenefitsFailure to PromoteFailure to Hire / Re-hireNegative Performance EvaluationThreat to Take any of the Above ActionsHarassment / IntimidationOther
When did you suffer the most recent adverse action?*

MonthDayYear
(If you cannot remember the exact date, please enter the approximate date.)
Why do you believe you suffered the adverse employment action(s)?*

Called / Filed complaint with OSHACalled / Filed complaint with another government agencyComplained to management about unlawful conditions, conduct, or practicesTestified or provided statement in a proceeding (e.g., government inspection or investigation)Because you engaged in protected concerted activities regarding workplace safety and/or health activitiesReported an injury, illness, or accidentParticipated in safety and health activitiesRefusing to perform a task the employee believes is dangerous or illegalOther
How did your employer know that you were engaged in a protected activity?*
How do you believe that the negative action was related to the protected activity?*
Is there anything else that you would like CONN-OSHA to know about what happened?
You may upload attachments related to your complaint.

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Name of the Municipality/State Agency Responsible for Retaliation*
Contact Name for the Municipality/State Agency Responsible for Retaliation*

First NameLast Name
Phone Number for the Municipality/State Agency Responsible for Retaliation*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address for the Municipality/State Agency Responsible for Retaliation
example@example.com
Mailing Address of the Municipality/State Agency Responsible for Retaliation*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am an:*

EmployeeEmployee Representative
Complainant or Complainant's Representative Name*

First NameLast Name
Complainant or Complainant's Representative Phone Number*
Format: (000) 000-0000.
Complainant or Complainant's Representative E-mail Address*
example@example.com
Complainant or Complainant's Representative Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please verify that you are human.*
For verification purposes, please trace the image presented:*
Should be Empty:

Whistleblower Retaliation Complaint Form

Please Note: