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Leave Rights Complaint Form

PAID LEAVE COMPLAINT: 

Please use this form to file a complaint if you believe you were wrongfully denied leave under the:

• Paid Leave for All Workers Act. This can include improper accrual, use, or rollover of paid time off, as well as records violations, retaliation, or no public notice. 
• Child Bereavement Leave Act
• Family Bereavement Leave Act
• Employee Sick Leave Act

A complaint form in PDF format is available. Download to your computer, fill-in, and save the completed form. Email to DOL.PaidLeave@illinois.gov.

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Employee Information

Employee Name

Employee Address

Employee City

Employee State

IL 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

Employee Zip Code

Employee Email Address

Employee Phone

I agree to allow the Illinois Department of Labor to email me about my complaint, including sending me documents by email.

Yes

No

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Employer Information

Business Name

Industry

Select Industry ... Aerospace Agriculture Airline Automotive Biotechnology Call Centers/Customer Service Chemical Child Care/Elder Care Cleaning Services - Home & Office Construction Consulting Education Energy Entertainment & Leisure Financial Services Government Hair & Beauty Insurance Landscaping Laundry / Dry Cleaning Legal Lodging / Hospitality Manufacturing Media Non-Profit Other Placement Services / Headhunters / Temp Agencies Real Estate Restaurant Retail Security Shipping / Logistics Technology Telecommunications Transportation Waste Management Wholesale

Business Address

Business City

Business State

IL 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

Business Zip Code

Business Owner(s) Name(s)

Employer Contact Name

Employer Contact Phone

Supervisor Name, if different than Contact

Supervisor Phone

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Employment information

Job Title

Main Job Duties

Are you still employed by this business?

Yes

No

If no, date of separation/last day worked?

Rate of Pay

Rate of Pay (Hourly, Weekly, Monthly)

Hourly

Weekly

Bi-Weekly

Monthly

Do you receive tips?

Yes

No

If you do not work at the business address above, what is the address of your work location?

Do you work remote?

Yes

No

Are you a member of a union?

Yes

No

If yes, what is the name/local of your union?

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Complaint Reason Details

Check the box(es) to indicate reason(s) for filing this Complaint.

I took leave from work and wasn't paid for it, or was paid too late.

I was not allowed to take leave from work.

I took leave or requested to take leave from work and was fired or punished because of it.

My employer did not keep accurate records of the paid leave I am owed.

My employer did not post a public notice about workers' rights under the Paid Leave for All Workers Act.

My employer violated an unpaid leave law (Child Bereavement Leave, Family Bereavement Leave, Employee Sick Leave).

Other

Other Reason, if checked above.

Explain why you believe the employer violated the Paid Leave for All Workers Act or other applicable leave right laws. List the dates, hours, or specific details that support your complaint. Attach additional sheets and information, if necessary.

What is the total amount of paid leave hours you believe you are owed? (If you are unsure, provide an estimate.)

Do you believe that the same or similar violations are impacting other employees at the workplace?

Yes

No

Not Applicable

Did you ask your employer to pay you the wages you were due, or to cure or resolve the issue?

Yes

No

Name and title of the person you asked

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Attachments

Please attach any of the following documents if you have them:  

• Copy of your last paycheck
• Copy of your latest W2
• Copies of wage records or paystubs for relevant time period
• Relevant pages from Employee Handbook or Manual
• Any communications between you and your employer on this request
• Other relevant documents

Attachment(s)

Attach

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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.

What is your race?

American Indian/Alaskan Native  Asian/Asian American  African American/Black  Native Hawaiian and Other Pacific Islander  Middle Eastern North African White/European American  Some Other Race Alone Two or More Races  Prefer Not to Answer 

What is your ethnicity?

Latina/Latino/Latinx/Hispanic  Other category not specified Prefer Not to Answer 

What is your gender identity?

Man Woman Non-binary, gender non-conforming Other category not specified Prefer Not to Answer 

What is your sexual orientation?

Bisexual Gay Lesbian Queer Questioning and/or unsure Straight (heterosexual) Other category not specified Prefer not to answer

Do you have a disability?

Yes No Prefer not to answer

What is your primary language?

English Spanish Polish Chinese (including Mandarin, Cantonese) Tagalog (Including Filipino) Hindi Arabic Other category not specified Prefer not to answer

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I understand that in general the public has the right, under FOIA, to request most information kept as part of any public record, however, the IDOL, will endeavor to keep the confidentiality of a complainant or witness to the maximum extent allowable by law.

I hereby certify that the application, including attachments, is true and accurate to the best of my knowledge.

Name

Date

Reset

Submit