Idaho Dept. of Labor
TO BE COMPLETED BY THE COMPLAINANT:
1. Name of Complainant (Last name, first name, middle initial)
2. Permanent Address
3. Temporary Address (if appropriate)
4. Permanent Telephone
5. Email Address (if available)
6. Name of person against whom the complaint is made
7. Name of Employer / Labor office
8. Address of Employer / Labor office
9. Telephone of Employer (if available)
10. Email Address (if available)
(Explain as clearly as possible and attach any pertinent documentation. Feel free to answer these questions on a separate piece of paper, if you wish):
a. What happened? (Please be specific about the actions or statements made)
b. Who was involved, including witnesses? (Name, address, phone)
c. When and where did it happen? (Include dates, times and locations)
d. How were you treated differently? Why do you think you were treated differently?
e. How would you like this complaint to be resolved?
12. Electronic Signature:
I CERTIFY that I am
(name of signer) and I CERTIFY the information furnished is true and accurate to the best of my knowledge. I AUTHORIZE the disclosure of this information as needed for the proper investigation and enforcement of my complaint. I UNDERSTAND my identity will be kept confidential to the maximum extent possible, consistent with applicable law and a fair determination of my complaint. I also understand it is against the law for my employer to discharge, intimidate, retaliate, coerce or discriminate against me for filing this complaint.
13. Date signed:
The customer submitting this complaint either requested assistance or submitted the complaint form by email or on paper. I have completed this form based on the information provided by the customer to the best of my ability.
Name of representative/interpreter
You may attach up to five supporting documents. NOTE: Each file must be less than 1.5 MB in size. Only the following file types are allowed: pdf, bmp, gif, jpg, jpeg, png
Idaho Department of Labor
Brad Little, Governor
Jani Revier, Director
An Equal Opportunity Employer and Service Provider