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Whistleblower Retaliation Complaint Form
You must have JavaScript enabled to use this form.
VSA, Title 21, Chapter 3, Section 231 of the Vermont Occupational Safety and Health Act protects employees who raise concerns about safety and/or health at their workplace, report a workplace injury or participate in other endeavors in the furtherance of occupational safety and health and suffer retaliation as a result.
If you believe you are a victim of whistleblower retaliation related to occupational safety and health, please fill out the below form.
NOTE:
For all other forms of retaliation or discrimination based on race, color, religion, national origin, sex, sexual orientation, gender identity, ancestry, place of birth, age, crime victim status, or physical or mental condition, please inquire with the
Vermont Attorney General’s Office
.
If you believe that you are a victim of whistleblower retaliation, please use this confidential form:
Name of Company Responsible for Retaliation
Telephone Number for the Responsible Company
I am a:
Employee
Representative of Employees
Complainant Name
First Name
Last Name
Last Name
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
Address Line 1
Address line 2
Address line 2
City
City
State
State
Zip
Zip
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
Organization Name
Your Title
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