Retaliation Complaints If you believe that you are a victim of whistleblower retaliation, please use this form: VOSHA Retaliation Complaint Name of Company Responsible for Retaliation*Phone of Responsible CompanyI am a(n):EmployeeRepresentative of EmployeesComplainant name*FirstLastIf 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 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodeDescription 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 titleOrganization NameYour title