Whistleblower Retaliation Complaint 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

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

City

State

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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