Wage Retaliation Complaint Form
PLEASE NOTE: This form is for Wage Retaliation Complaints pursuant to Conn. Gen. Stat. Sec. 31-69b. If you wish to file a complaint for unpaid wages, payment at less than minimum wage, unpaid overtime or other matters relating to wages or workplace standards, please file a complaint with our Wage and Workplace Standards Division. Complaints filed with the Legal Division are regarding retaliation.
“*” 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:
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Termination / Layoff
Discipline
Demotion / Reduced Hours
Suspension
Denial of Benefits
Failure to Promote
Failure to Hire / Re-hire
Negative Performance Evaluation
Threat to Take any of the Above Actions
Other
When did you suffer the most recent adverse action?
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Month
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Day
Year
(If you cannot remember the exact date, pleaseenter the approximate date.)
Why do you believe you suffered the adverse employment action(s)?
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Called / Filed complaint with CT DOL Wage and Workplace Standards Division
Complained to management about unlawful conditions, conduct, or practices
Testified or provided statement in a proceeding (e.g., government inspectionor investigation)
Other
How did your employer know that you were engaged in a protected activity?
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How do you believe that the negative action was related to the protectedactivity?
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Is there anything else that you would like the Legal Division to know about what happened?
You may upload attachments related to your complaint.
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Name of the Employer Responsible for Retaliation
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Contact Name for the Employer Responsible for Retaliation
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First Name
Last Name
Phone Number for the Employer Responsible for Retaliation
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Please enter a valid phone number.
Format: (000) 000-0000.
Email Address for the Employer Responsible for Retaliation
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example@example.com
Mailing Address of the Employer Responsible for Retaliation
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am an:
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Employee
Employee Representative
Complainant or Complainant's Representative Name
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First Name
Last Name
Complainant or Complainant's Representative Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Complainant or Complainant's Representative E-mail Address
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example@example.com
Complainant or Complainant's Representative Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please verify that you are human
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Draw image for verification:
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Submit
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