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COMPLAINT FORM

TO BE COMPLETED BY THE COMPLAINANT:

COMPLAINANT INFORMATION

RESPONDENT INFORMATION

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

6.Name of person against whom the complaint is made

2.Permanent Address (Number, street, city, state, zip code)

7.Name of Employer / IDOL office


City State Zip

3.Temporary Address (if appropriate)

8.Address of Employer / IDOL office

City State Zip

4.Permanent Telephone    Temporary Telephone

9.Telephone of Employer / IDOL office

   

5.E-mail Address (if available)

10.E-mail Address (if available)

11.STATEMENT (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.


Signed: 

13. Date signed:  12/12/2017

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 1.5 MB in size. Only the following file types are allowed:  doc,docx,xls,xlsx,ppt,pptx,txt,pdf,rtf,wri,wps,wpd,odt,ods,bmp,jpg,jpeg,png,gif



  
       

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