Vessa Complaint Form - Illinois Department Of Labor Page 2
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1
2VICTIMS’ ECONOMIC SECURITY
PLEASE PRINT OR TYPE ALL INFORMATION
AND SAFETY ACT (VESSA)
Use additional sheets if necessary. Attach copies of all supporting documentation and
COMPLAINT FORM
other evidence. A copy of this sheet will be sent to the 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
I. EMPLOYER INFORMATION:
II. EMPLOYEE INFORMATION:
___________________________________________________
___________________________________________________
Employer Name
Last Name,
First Name
-
-
___________________________________________________
____________
__________
__________________
Address
Social Security Number
___________________________________________________
III. TERMS OF EMPLOYMENT:
City
State
Zip
___________________________________________________
1. Did you sign an employment contract or agreement?
Corporation Name, if any
Yes
No (If “yes”, please attach a copy.)
__________________________
(_____)________________
2. Were you an independent contractor?
Employer Contact Name
Contact Phone #
Yes
No
__________________
_____________________________
Number of Employees
Industry of Employer
3. In what city and state did you perform your work?
Is this employer still in business?
Yes
No
____________________________________________________
IV. COMPLAINT DETAILS:
4. Did you request to take VESSA leave?
Yes
No
5. Did your employer permit you to take VESSA leave?
Yes (If “yes”, what were the beginning and end dates of each leave period? __________________________________________.)
No
(If “no”, state the reason, if any, your employer
gave you for denying VESSA leave: __________________________________________________________________.)
6. Did you voluntarily elect to substitute vacation, sick leave, and/or paid time off during any portion of VESSA leave?
Yes
No
7. Did your employer maintain the confidentiality of your request to take VESSA leave?
Yes
No
8. Did your employer maintain your group health plan benefits during your VESSA leave?
Yes
No
9. Did your employer restore you to the same or equivalent position upon your return from leave?
Yes
No
(If “no”, please explain. ___________________________________________________________________________________.)
10. As a result of VESSA leave, did you forfeit seniority or employment benefits accrued prior to the date of leave?
Yes
No
(If “yes”, please explain. __________________________________________________________________________________
_____________________________________________________________________________________________________.)
11. Were you discharged?
Yes
No
(If “yes”, state reason: _______________________________________________________.)
12. Did your employer harass, discriminate against, or deny you any other right under VESSA?
Yes
No
(If “yes”, please identify each specific violation, and attach additional sheets, if necessary. _______________________________
_____________________________________________________________________________________________________.)
V. CERTIFICATION & SIGNATURE:
Please sign, date, and return this form with two (2) copies of any attachments to the Illinois
Department of Labor at the address listed at the top of this form.
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.
/
/
Date: _____
_____
________
Employee’s Signature _______________________________________________________________
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