PRRA Complaint Form

Please view the Personnel Records Review Complaint form instructions

* indicates required field

Employee Information

First Name

Last Name

Address

City

State

ZIP Code

Phone

I consent to notification by email.

Yes

I want documents and communications to be sent to my representative:

Representative Name

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

Representative Affiliation

E.g. attorney, union, family member, etc.

Representative E-Mail

Employment Information

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?

Have you filed a lawsuit in court against your employer trying to get your personnel records?

Yes

I don't know

Employer Information

Employer Name

Name of company complaint is against

Employer Address

Employer City

Employer ST

Employer ZIP Code

Employer Contact Name

Employer Contact Phone

Employer E-Mail

Does the employer have 5 or more employees?

Failure to Provide Personnel Records

Has your employer denied your request for personnel records?

When did you make your request for personnel records?

How did you make your request?

When did you last review your records?

Which personnel records have been denied?

Please list any specific personnel records that you requested that were not included in your personnel file. If your entire personnel file was not provided, you can state “entire personnel file.

Dates request(s) were denied by Employer:

I would like to:

Inspect my personnel file in the employer’s office

Make a copy of my personnel file

Receive a copy of my personnel file to the following home address or email address noted above.

Other Violations of the Act

Disciplinary Records Revealed?

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

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?

If yes, please explain:

Other violations of the Personnel Records Review Act?

If you believe your employer has committed another violation of the Act, please explain.

Attachment(s)

Please attach any relecant documents, including any written request for personnel records, and the employer’s response, if any.

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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