PRRA Complaint Form

Please view the Personnel Records Review Complaint form instructions

* indicates required field

First Name

Last Name

Address

City

State

ZIP Code

Phone

Employment Begin Date

I still work here?

Employment End Date

Subject To Recall

Recall Date

If subject to a layoff, what was the recall date, if any?

Representative Name

Employee's representative, e.g. attorney, union, etc.

Representative E-Mail

Employer Name

Name of company complaint is against

Employer Address

Employer City

Employer ST

Employer ZIP Code

Employer Contact Name

Employer Contact Phone

Does the employer have 5 or more employees?

Employer E-Mail

Date of Last Review of Records

Which specific items do you wish to review?

Has your employer refused you access to your records?

Disciplinary Records Revealed?

If your employer, without notice or authorization, has disclosed your disciplinary records, please explain.

Information Not In Agreement

Non-related Records Kept?

Has your employer gathered or kept a record of your associations, political activities, publications, communications, or non-related activities without your written authorization?

Attachment(s)

Please attach any additional document(s).

Attachment(s)

Accept and Submit

BY ACCEPTING AND SUBMITTING THIS FORM, THE COMPLAINANT AFFIRMS AND CERTIFIES THAT ALL INFORMATION PROVIDED AND THE STATEMENTS MADE HEREIN ARE TRUE, CORRECT, AND COMPLETE.

PRRA Complaint Form

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PRRA Complaint Form

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