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VESSA Complaint Form

This complaint form is for VESSA. More information about VESSA is available at https://labor.illinois.gov/laws-rules/conmed/vessa.html.

 

VICTIMS’ ECONOMIC SECURITY AND SAFETY ACT (VESSA) COMPLAINT FORM
I. EMPLOYEE INFORMATION

If this application is being submitted by a representative of the employee or if future communications should be sent to a representative of the employee, please complete the following:

II. EMPLOYER INFORMATION:
III. TERMS OF EMPLOYMENT 

If yes, attach below.

IV. COMPLAINT DETAILS:
    V. CERTIFICATION & SIGNATURE
    I HEREBY CERTIFY that the statements herein, including attachments, are true and accurate to the best of my knowledge and belief. I  understand that acceptance of this complaint by the Illinois Department of Labor does not guarantee any specific result. I authorize the Illinois Department of Labor to receive any monies paid and to mail such monies to me at my own risk.

    Demographic information

    IDOL asks for this voluntary information in order to learn more about the people who file complaints with us. Any information you provide will not be shared or used in relation to your complaint.