Retaliation (Discrimination) Complaint Form. This is a California form and can be use in DLSE Forms Workers Comp.
Tags: Retaliation (Discrimination) Complaint, DLSE RCI-1, California Workers Comp, DLSE Forms
Retaliation Complaint FOR OFFICE USE ONLY Taken by: Taken by: Office: Employee Name: PLEASE PRINT OR TYPE ALL INFORMATION R efer to the accompanying Guide to assist you in filling out this form. Taken by: Date filed: LC Violation : Case #: Wage Complaint: YES NO Action: SIC #: PRELIMINARY QUESTIONS **The following questions are asked in relation to your current complaint ** 1. Have you made a health and safety complaint to your employer or supervisor? YES , on: // To whom : , Title: NO 2. Have you made a health and safety related retaliation complaint against your employer with a government agency? YES , on: // With whom: NO [If you have a health & safety related retaliation complaint, you may also make a complaint with Federal OSHA within 30 days of the alleged event.] 3 . Did you speak with a Labor Commissioner Investigator d uring an inspection at your worksite? YES , on: // With whom: NO 4. Have you made a wage claim against your employer with the Labor Commissioner ? If so, where? YES , on: // NO [ If you have unpaid wages , y ou may file a wage claim Month Day Year 1 5. Are other employees also filing retaliation claims against your employer? YE S NO Part 1: LANGUAGE ASSISTANCE & REPRESENTATION 6 a . Do you need an interpret er? YES NO 6 b . Box 6 a, enter the language needed : 7 a . If you are being helped with your claim by a lawyer or other advocate, enter your and ORGANIZATION : 7 b ( ) 7 c . Y (Number, St reet, Floor, Suite) CITY STATE ZIP CODE Part 2: YOUR INFORMATION 8 . Your FIRST NAME 9 . Your LAST NAME 10 . HOME PHONE ( ) 11 . OTHER PHONE ( ) 1 2 . BIRTH DATE 1 3 . Your MAILING ADDRESS (Street Nu mber, Street Name, Apartment Number ) CITY STATE ZIP CODE 14. EMAIL Part 3: EMPLOYER INFORMATION 15. EMPLOYER / BUSINESS NAME(S) 1 6 . 1 7 . EMPLOYER PHONE ( ) 1 8 . ADDRESS of EMPLOYER / BUSINESS ( Street Number, Street Name , Floor, Suite) : CITY STATE ZIP CODE 1 9 . ADDRESS where you worked, if different from Box 1 8 (Number, Street, Floor, Suite): CITY STATE ZIP CODE 20. NAME of PERSON IN CHARGE (First Name, Last Name) 21. JOB TITLE / POSITION of PERSON IN CHARGE 2 2 . TYPE OF BUSINESS 23 . TYPE OF WORK PERFORMED 2 4 . TOTAL NUMBER OF EMPLOYEES 2 5 . EMPLOYER STILL IN BUSINESS? YES NO 2 6 . Check which box describes your employer , if you know : CORPORATION INDIVIDUAL /DBA PARTNERSHIP LLC LLP RCI 1 / RETALIATION COMPLAINT (REV. 1 1 /2012 ) (Page 1 of 4 ) American LegalNet, Inc. www.FormsWorkFlow.com PRINT YOUR NAME: FOR OFFICE USE ONLY Case #: Part 4: EMPLOYMENT STATUS 2 7 . DATE OF HIRE / / Month Day Year 2 8 . Check which box applies to you: Still working for employer QUIT on / / DISCHARGED on / / Month Day Year Month Day Year Suspended on / / Ot her (specify) : Month Day Year 29 . If you no longer work for the employer, what was your fina l rate of pay ? $ / (for example, $10/hour) 30. Last job title with Employer Job Title: Part 5: YOUR COMPLAINT INSTRUCTIONS: Please see the Instructions Sheet to help you answer the following questions. G ive a written statement to each question. An incomplete form will result in delays . While it is important to know the names of management involved, do not include the names of the any of your witnesses on th is page. 31. W hat changes have occurred at work that caused you to make this complaint? T ermination Suspension D emotion C hange in hours Change in pay Other : D isciplinary action/written warning Threat T r ansfer Forced to resign/quit Date of change in employment : // Name (s) of person (s) carrying out change : Title: Title: Please describe what happened. 32 a . What reason would the employer give for the changes that you experienced that are described in question 31 above? What rig ht did you exercise or action did you take that happened before the change in your employment described in question 31? 32b . Describe how your employer knew about the activity or actions (e.g., exercising your rights) in question 32a . ? RCI 1 / RETALIATION COMPLAINT (REV. 1 1 /2012 ) (Continued, Page 2 of 4) American LegalNet, Inc. www.FormsWorkFlow.com RCI 1/ RETALIATION COMPLAINT (REV. 11/2012) (Continued, Page 3 of 4) PRINT YOUR NAME: FOR OFFI CE USE ONLY Case #: *THIS PAGE IS CONFIDENTIAL* Part 6 : WITNESSES All witnesses are confidential, and the Labor Commissioner will not reveal their identities u nless it becomes necessary to proceed with the investigation or to enforce the Labor Commissi . 33. Please list any witnesses to the even ts described in questions 31, 32 a . and 32b . Name: Ti tle: Address: Phone Number: Email Address : Describe what they saw or heard in connection to your complaint: Name: Title: Address: Phone Number: Email Address: Describe what they saw or heard in connection to your complaint: Name: Title: Address: Phone Number: Email Address: Describe what they saw or heard in c onnection to your complaint: Briefly describe what kind of remedy you are seeking. What do you hope happens as a result of filing this complaint? NEW EMPLOYMENT Have you started a new job? Yes No Date you started new job: / / (DD/MM/YY) Name of New Employer: Rate of pa y: $ / (for example, $10/hour) Part 7 : REMEDIES I h ereby certify that the information I have provided is true to the best of my knowledge and/or recollection. Signed: Date: Print Name: American LegalNet, Inc. www.FormsWorkFlow.com AUTHORIZATIONS TO RELEASE INFORMATION RCI 1 / RETALIATION COMPLAINT (REV. 11/2012) (Continued, Page 4 of 4) PERSONNEL FILE RELEASE: I, , hereby authorize (Full name) (Employer name) t o release my Pe rsonnel records to the Division of Labor Standards Enforcement. I specifically authorize the release of all records in my personnel file. This authorization is valid for a period of one year from the date of my signature. Signature of Employee Date of Signature Cal - OSHA RELEASE : If you have a health and safety related complaint, please fill out the following release. I authorize a DLSE investigator to inspect the o riginal file contents and to be provided with a complete copy of the file, including the complaint that I filed with Cal - OSHA against the employer named above. By my signature I authorize a Cal - OSHA representative to discuss my complaint and the file deta iling the correspondence and investigation into my complaint with the Division of Labor Standards Enforcement. Signature Date Print Name American LegalNet, Inc. www.FormsWorkFlow.com LABOR COMMISSIONER, STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS 226 DIVISION OF LABOR STANDARDS ENFORCEMENT RCI 1.1 (Rev. 10/01/2018) INSTRUCTIONS AND GUIDE FOR FILING A RETALIATION COMPLAINT Fill out and submit the 223Retaliation Complaint224 Form (RCI 1). Please read the following Instructions to ensure that you are completing the Form correctly. Please respond fully to all questions. An incomplete Form will result in delayed processing. WHAT TO EXPECT AFTER YOU FILE YOUR COMPLAINT 1) Investigation. In most cases, you will receive a letter from the Labor Commissioner letting you know to whom your complaint has been assigned. After this happens, a deputy will contact you to interview you, and will also most likely interview your witnesses, the employer, and the employer222s witnesses. In addition to the investigation, the deputy may also discuss settlement options with you. 2) Conference & Hearing. In some cases, you may be asked to come to an office of the Labor Commissioner for a conference or a hearing. If you receive one of these notices, the deputy will explain what you need to bring with you. 3) Determination. After the deputy concludes his or her investigation, he or she will write a report and the Labor Commissioner222s Office will make a decision, known as a determination, on your case. If the decision is in your favor, the Labor Commissioner222s Office will work with the employer to enforce the decision. If the decision is in the favor of the employer, in certain very limited circumstances you may have a right to an appeal, the details of which you will be described in the determination. 4) Staying in Touch. It is your responsibility to keep the deputy informed of any address or telephone number changes. If the deputy is unable to locate yo