Retaliation Complaints | Vermont Department of Labor

report-whistleblower-retaliation If you believe that you are a victim of whistleblower retaliation, please use this form:

Name of Company Responsible for Retaliation*
Phone of Responsible Company
I am a(n):
- Employee
- Representative of Employees
Complainant name*
FirstLast
If this box is checked, this submission shall be considered as an authorized written signature.
- This constitutes my electronic signature.
Complainant email address*
Complainant Telephone Number*
Complainant Mailing Address*
Street AddressAddress Line 2CityStateZIP Code
Description of Complaint:*
Protected Activity:*
(i.e. bringing a safety complaint to the attention of the supervisor, filing a workers’ compensation claim, filing a VOSHA complaint, etc.)
Negative Action Taken:*
(i.e. demotion, firing, etc.)
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