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Retaliation (Discrimination) Complaint DLSE RCI-1 - California

Retaliation (Discrimination) Complaint Form. This is a California form and can be used in DLSE Forms Workers Comp .
 Fillable pdf Last Modified 12/9/2013
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Retaliation Complaint PLEASE PRINT OR TYPE ALL INFORMATION Refer to the accompanying Guide to assist you in filling out this form. Taken by: Taken by: Date filed: Wage Complaint: FOR OFFICE USE ONLY Taken by: Office: Employee Name: LC Violation: Action: Case #: SIC #: YES NO 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 during 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: _________/________/________ Month Day Year NO [ If you have unpaid wages, you may file a wage claim by filling out another form, "DLSE FORM 1."] 5. Are other employees also filing retaliation claims against your employer? YES NO I DON'T KNOW Part 1: LANGUAGE ASSISTANCE & REPRESENTATION 6a. Do you need an interpreter? and ORGANIZATION: YES NO 6b. If you checked "YES" to Box 6a, enter the language needed: 7b. ADVOCATE'S PHONE ( ) d. Your ADVOCATE'S EMAIL 7a. If you are being helped with your claim by a lawyer or other advocate, enter your ADVOCATE'S NAME 7c. Your ADVOCATE'S MAILING ADDRESS (Number, Street, Floor, Suite) CITY STATE ZIP CODE Part 2: YOUR INFORMATION 8. Your FIRST NAME 9. Your LAST NAME 10. HOME PHONE 11. OTHER PHONE 12. BIRTH DATE ( 13. Your MAILING ADDRESS (Street Number, Street Name, Apartment Number) 14. EMAIL CITY ) ( ) STATE ZIP CODE Part 3: EMPLOYER INFORMATION 15. EMPLOYER / BUSINESS NAME(S) 16. EMPLOYER'S VEHICLE LICENSE PLATE # 17. EMPLOYER PHONE ( ) STATE ZIP CODE 18. ADDRESS of EMPLOYER / BUSINESS (Street Number, Street Name, Floor, Suite): CITY 19. ADDRESS where you worked, if different from Box 18 (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 22. TYPE OF BUSINESS 23. TYPE OF WORK PERFORMED 24. TOTAL NUMBER OF EMPLOYEES 25. EMPLOYER STILL IN BUSINESS? YES NO DON'T KNOW LLC LLP 26. Check which box describes your employer, if you know: CORPORATION RCI 1/ RETALIATION COMPLAINT (REV. 11/2012) (Page 1 of 4) INDIVIDUAL /DBA PARTNERSHIP American LegalNet, Inc. PRINT YOUR NAME: ________________________________________ FOR OFFICE USE ONLY Case #: Part 4: EMPLOYMENT STATUS 27. DATE OF HIRE 28. Check which box applies to you: ____/____/_____ Month Day Year Still working for employer QUIT on ___ /___/____ Month Day Year DISCHARGED on ___/___/____ Month Day Year Suspended on ___ /___/____ Month Day Year Other (specify): ________________________________________ 30. Last job title with Employer Job Title: ____________________________________ 29. If you no longer work for the employer, what was your final rate of pay? $ _____________________/________________ (for example, $10/hour) Part 5: YOUR COMPLAINT INSTRUCTIONS: Please see the Instructions Sheet to help you answer the following questions. Give 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 this page. 31. What changes have occurred at work that caused you to make this complaint? Termination Suspension Demotion Change in hours Change in pay Other : ________________ Disciplinary action/written warning Threat Transfer Forced to resign/quit Date of change in employment: ___/___/___ Name(s) of person(s) carrying out change: ________________________ Title: ________________________ Title: Please describe what happened. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 32a. What reason would the employer give for the changes that you experienced that are described in question 31 above? What right 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. 11/2012) (Continued, Page 2 of 4) _____________________________________ _____________________________________ American LegalNet, Inc. PRINT YOUR NAME: ________________________________________ FOR OFFICE USE ONLY Case #: *THIS PAGE IS CONFIDENTIAL* Part 6: WITNESSES All witnesses are confidential, and the Labor Commissioner will not reveal their identities unless it becomes necessary to proceed with the investi
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