Illinois Department of Labor
Notice of Discrimination Complaint
1
INFORMATION ABOUT FILING A DISCRIMINATION COMPLAINT
WITH THE ILLINOIS DEPARTMENT OF LABOR
FOR
ILLINOIS PUBLIC SECTOR EMPLOYEES ONLY:
Section 110 of the Illinois Occupational Safety and Health Act, prohibits any person
from discharging or in any manner retaliating against any employee because the
employee has complained about unsafe or unhealthful working conditions or exercised
other rights under the Act.
The law requires that complaints be filed within 30 days after the alleged retaliatory
action. A complaint of retaliation filed with IDOL must allege that the complainant
engaged in activity protected by the discrimination provisions (such as reporting a
violation of law), the employer knew about or suspected that activity, the employer
subjected the complainant to an adverse action or threatened such action, and the
protected activity motivated or contributed to the adverse action. Adverse actions
include discharge, demotion, denial of promotion, harassment and generally any other
action that would dissuade a reasonable employee from engaging in protected activity.
Upon receipt of a complaint, IDOL will review the complaint form to determine whether
to conduct an investigation. If the complaint form is not complete or more information
is needed, IDOL will contact the complainant by letter. It is very important that a
complainant respond to such contact; if a complainant is unresponsive, IDOL cannot
proceed with an investigation and the complaint will be dismissed. If IDOL proceeds
with an investigation the employer will be notified of the allegation and permitted to
submit a response.
BY LAW, A COMPLAINANT’S INFORMATION, INCLUDING HIS/HER IDENTITY,
MUST BE PROVIDED TO THE EMPLOYER. A WHISTLEBLOWER COMPLAINT
FILED WITH OSHA CANNOT BE FILED ANONYMOUSLY.
Mail completed complaint form to:
Illinois Department of Labor
Illinois OSHA Division
Lincoln Tower Plaza
524 South 2nd Street, Suite 400
Springfield, Illinois 62701
or email:
dol.whistleblower@illinois.gov
Illinois Department of Labor
Notice of Discrimination Complaint
IDOL (Rev.3/24)
2
PART 1 – EMPLOYEE INFORMATION
1. Name (last, first, middle initial) (required):
2. Present Address (Street, City, State, Zip) (required):
3. Telephone Numbers (include area code) (at least one required):
Home: ( )
Work: ( )
Cell: ( )
4. Email Address:
5. Hire Date (Month/Day/Year):
6. Choose One:
8. Work Site Address at Place of Employment where Alleged Retaliation
Occurred (Street, City, State, Zip):
7. If You No Longer Work For This Employer, Date The Job Ended (Month/
Day/Year):
Still Employed
Fired
Laid Off
Resigned
Illinois Department of Labor
Notice of Discrimination Complaint
IDOL (Rev.3/24)
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9. Job Title at Place of Employment where Alleged Retaliation Occurred:
10. Exclusive bargaining (union) representative (if any):
Yes No I don’t know
11. The person filing this complaint is (check one box):
Employee Representative of Employee
Other (specify)
If you are an authorized representative of the complainant, please complete Part
4 – Identification of Representative.
PART 2 – EMPLOYER CONTACT INFORMATION
12. Employer Name (required):
13. Name and Title of Management Person (for contact purposes only):
Name:
Title:
Phone:
Illinois Department of Labor
Notice of Discrimination Complaint
IDOL (Rev.3/24)
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14. Name and Title of Supervisor:
Name:
Title:
15. Employer Mailing Address (if different from worksite address in #8):
16. Employer Phone:
( )
17. Employer Fax:
( )
18. Employer Email:
19. Type of Business:
PART 3 – ALLEGATION OF DISCRIMINATION
Please answer the questions below in the space provided.
20. What management person is responsible for the retaliation that you are
reporting?
Name:
Position/Title:
Illinois Department of Labor
Notice of Discrimination Complaint
IDOL (Rev.3/24)
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□ Termination
21. What are the actions or events that you are reporting to IDOL? You may
check one or more of the boxes below, and/or describe the action(s) in the space
provided. (required)
□ Discipline □ Demotion/Reduced Hours
□ Denial of Benefits □ Failure to Promote □ Negative Performance Evaluation
□ Failure to Hire/Re-Hire □ Harassment □ Suspension
□ Threat to Take any of the Above Actions □ Other
(please describe):
22. When did the employer take these actions against you? Please list all
relevant date(s) to the best of your recollection. If you cannot remember the exact
date(s), please put the approximate date(s).
23. When did you first learn that the action(s) would be taken against you?
Please list all relevant dates(s) to the best of your recollection. If you cannot remember
the exact date(s), please put the approximate date(s).
24. What reason(s) did the employer give you for each of these actions?
Illinois Department of Labor
Notice of Discrimination Complaint
IDOL (Rev.3/24)
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25. Why do you believe the employer took these actions against you? You
may check one or more of the boxes below, and/or describe the reason in the space
provided.
□ Called/Filed with Another Agency
□ Reported an Accident or Injury
□ Called/Filed with Illinois OSHA
□ Complained to Management
□ Participated in Safety and Health Activities
□ Refused to Perform Task (please specify reason for refusal)
□ Testified or provided statement in investigation or other proceedings (please specify)
□ Other (please describe)
26. For any of the actions you listed in #25, please provide the relevant
date(s) you engaged in that activity.
27. Do you believe the employer knew you engaged in the activity described
in #25? If so, how do you think they learned of it?
Illinois Department of Labor
Notice of Discrimination Complaint
IDOL (Rev.3/24)
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Yes
28. Have you filed any previous complaints against this employer with
Illinois OSHA regarding these or similar retaliatory actions?
If yes, please provide the complaint number and date filed.
Complaint Number:
Date filed:
Yes
29. Have you taken any other action(s) to appeal, grieve, or report this
matter under any other procedure?
No
If yes, please list the agency/organization(s) with whom you have
appealed/grieved/reported this matter, the date filed, the current sta
tus of
the procedure, and any outcome:
No
PART 4 – IDENTIFICATION OF REPRESENTATIVE
Complete this part if you are an authorized representative of the complainant. If an
investigation is opened, you will be asked to submit a signed Designation of Representative
Form that will be sent to you.
If you are filing this complaint on your own behalf, do NOT complete this part.
Nam:ee:
Title:
Organization Name (if any):
Union Affiliation (if any):
Address (Street, City, State, Zip Code):
)
Phone
(day):
)
(
(
Phone (cell):
Email:
By checking this box, I certify that the named employee has authorized
me to act as their representative for purposes of this
complaint.
Illinois Department of Labor
Notice of Discrimination Complaint
IDOL (Rev.3/24)
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PART 5 – CERTIFICATION
NOTE: It is unlawful to make any false statement, representation or
certification in any document filed pursuant to the Occupational
Safety and Health Act, Section 120(c). Violations can be charged with
Class 4 felony
By checking this box, I certify that the information in this
complaint is true and correct to the best of my knowledge and belief.
Date:
