Whistleblowers' Complaint Form - New Hampshire Department Of Labor Form
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1STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
PO BOX 2076
CONCORD, NH 03302-2076
WHISTLEBLOWER’S COMPLAINT FORM
Filed pursuant to RSA 275-E:4 I
COMPLAINANT INFORMATION
Name____________________________________________________ S.S. No. (optional)_________________
Mailing Address_____________________________________________ Tel.___________________________
(Street) (City) (State) (Zip)
EMPLOYER INFORMATION
Name of Employer /Company _________________________________________________________________
Mailing Address____________________________________________________________________________
(Street) (City) (State) (Zip)
Employer Representative______________________________________ Tel.____________________________
Basis of whistleblower’s complaint (BE SPECIFIC)_______________________________________________
__________________________________________________________________________________________
Were you discharged? Yes___ No___ If Yes, on what date?_______________________
What date was the alleged discrimination, threat or retaliation against you made?_________________________
Is there a grievance procedure available at your place of employment? Yes____ No____
Did you follow the employer’s grievance procedure before filing this complaint? Yes____ No____
ATTACH ALL SUPPORTING DOCUMENTS
What relief are you seeking by this action?_______________________________________________________
COMPLETE APPROPRIATE SECTION
I. REPORTING [RSA 275- E: 2 I(a)]
What violation did you report (including violations concerning the gross mismanagement or waste of public
funds, property, or manpower, or evidences an abuse of authority or a danger to the public health and safety)?
__________________________________________________________________________________________
What date did you report the alleged violation to the employer?_______________________________________
Who violated the law or rule?___________________ When?________________ How?___________________
To whom did you report this?
______________________________________________________
(Name and Title)
If you did not report this alleged violation to your employer, please explain why.
__________________________________________________________________________________________
How long did you give the employer to correct the alleged violation?__________________________________
II. OBJECTION OR REFUSAL TO PARTICIPATE IN AN ILLEGAL ACTIVITY [RSA 275- E:2 I(b)]
What was the alleged illegal activity in which you were asked to participate?____________________________
By whom?_______________________________________ On what date?______________________________
III. PARTICIPATION [RSA 275-E:2 I(c)]
Did you participate in an investigation, hearing, inquiry, or court action? Yes____ No____
If Yes, which one?____________ On what date?____________ At what agency or court?__________________
IV. REFUSAL TO EXECUTE ILLEGAL DIRECTIVE [RSA 275- E:3]
What was the alleged illegal order you were asked to carry out?_______________________________________
By whom?_______________________________________ On what date?______________________________
V. PROTECTION OF PUBLIC EMPLOYEES [RSA 275- E:9]
What date did you report the alleged violation of fraud, waste or abuse in the expenditure of public funds or
relating to programs and operations involving the procurement of any supplies, services, or construction by
governmental entities within the state, to the NHDOL?_____________ NHDOL Case #: __________(required)
CERTIFICATION
I hereby certify that this is a true statement of the facts as is involved in this matter.
Signature________________________________________ Date______________________
Rev. 4/4/14
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