PRRA Complaint Form

First Name

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Last Name

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Address

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City

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State

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

ZIP Code

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Email

Phone

Employment Begin Date

Employment End Date

Subject To Recall

Yes No N/A

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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

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Employer City

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Employer ST

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Employer ZIP Code

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Employer Contact Name

Employer Contact Phone

Does the employer have 5 or more employees?

Yes No

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Employer E-Mail

Date of Last Review of Records

Which specific items do you wish to review?

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Has your employer refused you access to your records?

Yes No N/A

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Discplinary Records Revealed?

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

Information Not In Agreement

N/A Yes No

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Non-related Records Kept?

N/A Yes No

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

Accept and Submit

Yes

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.

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