F262-009-000 Industrial Insurance Discrimination Complaint Form 12-2017 Investigations PO Box 44277 Olympia WA 98504-4277 Call: 1-866-324-3310 or 30-902-9155 Email: CSIIIDComplaints@Lni.wa.gov Industrial Insurance Discrimination Complaint Form You must file your complaint within 90 days of the alleged violation. Case Number (Dept. Use Only) Your rights are: RCW 51.48.025 1) No employer may discharge or in any manner discriminate against any employee because such employee has filed or communicated an intent to file a claim for compensation or exercise any rights provided underthis title. However, nothing in this section prevents an employer from taking any action against a workerfor other reasons including, but not limited to, the worker222s failure to observe health or safety standards adopted by the employer, or the frequency or nature of the worker222s job - related accidents. 2) Any employee who believes that he or she has been discharged or otherwise discriminated against by an employer in violation of this section may file a complaint with the director alleging discrimination withinninety days of date of the alleged violation. Upon receipt of such complaint, the director shall cause aninvestigation to be made, as the director deems appropriate. Within ninety days of the receipt of acomplaint filed under this section, the director shall notify the complainant of his or her determination. Ifupon such investigation, it is determined that this section has been violated, the director shall bring an action in the superior court of the county in which the violation is alleged to have occurred. 3) If the director determines that this section has not been violated, the employee may institute the action on his or her own behalf. In any action brought under this section, the superior court shall have jurisdiction, for cause shown, torestrain violations of subsection (1) of this section and to order all appropriate relief including rehiring or reinstatement of the employee with back pay. Complainant222s Information Complainant222s (Your) Full Name Date of Birth Date of Complaint Current Address City State Zip Code Home Phone Number Cell Phone Number Injury Claim Number Date of Injury Do You Speak English? Yes No What is your preferred language for all communications with Labor & Industries? What is your preferred method of communication? Phone Mail Email Current Email Ad dress Employer Information Business Name Business Address City State Zip Code Supervisor222s Name Supervisor222s Phone Number Your Job Title How long did you work for the employer? Are you still employed with the employer? Yes No Was your employment terminated? Yes No Date Last Worked: Date Last Worked: American LegalNet, Inc. www.FormsWorkFlow.com F262-009-000 Industrial Insurance Discrimination Complaint Form 12-2017 Attorney Information Do you have an attorney representing you with this complaint? Yes No Attorney222s Name Attorney222s Phone Number Attorney222s Address City State Zip Code Injury and Discrimination Information Did you report your injury to the employer? Yes No Name and Title of the p er son you reported this injury to Are you released to work at this time? Yes Full Duty Light Duty No Are you presently on light duty/restrictions? Yes No Date You Returned to Work Anticipated Release for Work Date Date of Alleged Act of Discrimination Action Taken by Employer Why do you believe the employer took this action? If you need more space, attach additional pages. List the names, address, and phone numbers of the witnesses to the alleged act(s) of discrimination. Have you filed your complaint with any other age ncy? Yes No If 223Yes224, which agency/agencies have you contacted? I certify under the penalties of perjury that the information provided herein is the truth to the best of my knowledge. Print Name Signature Date Mail completed forms to: Department of Labor and Industries Investigations PO Box 44277 Olympia WA 98504-4277 Or email to: CSIIIDComplaints@Lni.wa.gov American LegalNet, Inc. www.FormsWorkFlow.com