Report Jobplace Discrimination | Vermont Department of Labor

Establishment Name*
Site Physical Address*
Street AddressAddress Line 2CityZIP Code
Mailing Address (If different)
Street AddressAddress Line 2CityZIP Code
Management Official
FirstLast
Phone
Type of Business
Discrimination Description*
Describe briefly the discrimination which you believe exist. Include the approximate number of employees exposed to or threatened by discrimination.
Discrimination Location*
Specify the particular building or worksite where the alleged violation exists
This condition has been brought to the attention of: (Choose all that apply)
- Employer
- Government Agency
I am a(n):
- Employee
- Representative of Employees
Please indicate your desire:
The VOSHA Act gives complainants the right to request that their names not be revealed to their employer. Providing your name and address will only allow VOSHA staff to communicate with you regarding your complaint.
- Do NOT reveal my name to my Employer
- My name may be revealed to my Employer
Complainant name*
FirstLast
Complainant email address*
Complainant Telephone Number*
Complainant Mailing Address*
Street AddressAddress Line 2CityStateZIP Code
If you are an authorized representative of employees affected by this complaint, please state the name of the organization that you represent and your title
Organization Name
Your title

If you are an authorized representative of employees affected by this complaint, please state the name of the organization that you represent and your title