DOL: IOSHA Whistleblower Protection Online Complaint Form

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DOL > IOSHA > IOSHA Home > IOSHA Whistleblower Protection Online Complaint Form IOSHA Whistleblower Protection Online Complaint Form

Whistleblower Complaint Questions

Please answer the following questions to help determine if we can accept your claim.

Required Field

Question 1Were you subject to discrimination or adverse employment action as a result of raising workplace safety and health related concerns? (Examples of types of discrimination, as well as examples of workplace safety and health related concerns can be found on the previous page.)

Whistleblower Protection Online Complaint Form

Employee Information

Full Legal Name:
Address:
City:
State:
Zip:
Phone Number:
() -
Home Phone:
() -
Email:
Number EE's:
Union:
Rate of Pay:
Job Title:
How Long Have You Been the Company?:

Employer Information

Company Name:
Address:
City:
State:
Zip:
Phone Number:
() -
Site Contact:
SIC Code:
What does the company do?:

Alleged Whistleblower Information

Date of Protected Activity:
Month Day Year
Why Do You Feel You Were Discriminated Against?:

You selected "other", please specify:
Date of Adverse Action:
Month Day Year
Alleged Discriminatory Action:

You selected "other", please specify:
Additional Comments:

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DOL > IOSHA > IOSHA Home > IOSHA Whistleblower Protection Online Complaint Form IOSHA Whistleblower Protection Online Complaint Form

Whistleblower Complaint Questions

Whistleblower Protection Online Complaint Form

Full Legal Name:

Address:

City:

State:

Zip:

Phone Number:

Home Phone:

Email:

Number EE's:

Union:

Rate of Pay:

Job Title:

How Long Have You Been the Company?:

Company Name:

Address:

City:

State:

Zip:

Phone Number:

Site Contact:

SIC Code:

What does the company do?:

Date of Protected Activity:

Why Do You Feel You Were Discriminated Against?:

Date of Adverse Action:

Alleged Discriminatory Action:

Additional Comments: