Vessa Complaint Form - Illinois Department Of Labor
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1
2VICTIMS’ ECONOMIC SECURITY
PLEASE PRINT OR TYPE ALL INFORMATION
AND SAFETY ACT (VESSA)
Carefully read the instructions and complete the employee information on this sheet.
COMPLAINANT CONTACT SHEET
This page is not intended for your employer.
Illinois Department of Labor
160 North LaSalle Street, Suite #C-1300
FOR OFFICE USE ONLY: Claim Number _____________ Received ________
Chicago, Illinois 60601
(312) 793-6797
Complainant Contact Sheet
INSTRUCTIONS:
1.
For your complaint to be processed, you must complete and return to the Illinois Department of Labor an original
signed copy of both this Complainant Contact Sheet and the attached VESSA Complaint Form.
2.
Answer all questions completely. Some questions require you to submit supporting documents. Attach TWO (2)
complete copies of all supporting documents to your claim. Incomplete forms will be returned for completion, and this
will delay the processing of your complaint.
3.
If you move after filing your complaint, please notify the Department in writing at once. Your claim may be
dismissed if we cannot locate you.
4.
Upon receipt of your properly completed Complainant Contact Sheet, VESSA Complaint Form, and TWO (2) copies of
all supporting documents, the Department will investigate your claim. You may be required to submit additional
information and/or participate in investigative hearings during the investigation. You will be notified in writing of any
action required on your part.
NOTE: A copy of your Complaint Form and all supporting documentation will be sent to your employer. However,
IDOL will make reasonable efforts to prevent distribution of personal contact information (this Complainant
Contact Sheet) outside of State of Illinois personnel.
EMPLOYEE INFORMATION:
______________________________________________________
(_________)_____________________________
Last Name,
First Name
Home Phone Number
______________________________________________________
(_________)_____________________________
Address
Work Phone Number
______________________________________________________
____________-__________-________________
City
State
Zip
Social Security Number
Please provide the name and telephone number of someone who will know how to reach you:
_________________________________________
(_____)_______________
__________________________
Last Name,
First Name
Phone Number
Relationship to Employee
Is this complaint being brought by someone other than the employee?
Yes
No
(If “yes”, provide contact
information below.)
______________________________________________________
(_________)_____________________________
Last Name,
First Name
Complainant Phone Number
______________________________________________________
_______________________________________
Address
Complainant Organization Name
______________________________________________________
_______________________________________
City
State
Zip
Complainant Relationship to Employee
OPTIONAL EMPLOYEE INFORMATION — FOR RESEARCH PURPOSES ONLY
Race:
White
Black
Other
Ethnicity:
Hispanic
Gender:
Male
Year of Birth: ____________
Asian
Native American
Non-Hispanic
Female
Proceed to VESSA Complaint Form
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