COMPLAINT FORM

TO BE COMPLETED BY THE COMPLAINANT:

COMPLAINANT INFORMATION

1. Name of Complainant (Last name, first name, middle initial)

2. Permanent Address

City

State

Zip

3. Temporary Address (if appropriate)

4. Permanent Telephone

Temporary Telephone

5. Email Address (if available)

RESPONDENT INFORMATION

6. Name of person against whom the complaint is made

7. Name of Employer / Labor office

8. Address of Employer / Labor office

City

State

Zip

9. Telephone of Employer (if available)

10. Email Address (if available)

11. STATEMENT Explain as clearly as possible. Attach any pertinent documentation at the end of this form.

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?

f. Have you ever participated in the Workforce Innovation and Opportunity Act (WIOA) program?

12. Electronic Signature:

I CERTIFY that I am

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.

Signed:

13. Date signed: 4/25/2024

14. 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

Signature

You may attach up to five supporting documents. NOTE: Each file must be less than 5 MB in size. Only the following file types are allowed: pdf, bmp, gif, jpg, jpeg, png

Attach document 1 File1

Attach document 2 File2

Attach document 3 File3

Attach document 4 File4

Attach document 5 File5

Idaho Department of Labor
Brad Little, Governor
Jani Revier, Director
Labor.Idaho.gov
Idaho.gov
Accessibility
Privacy
Security
Cybersecurity.Idaho.gov
An Equal Opportunity Employer and Service Provider