WHISTLEBLOWER RETALIATION COMPLAINT

FILING AGENCY SELECTION

Select the appropriate filing agency based on the underlying protected activity:

☐ OSHA (Occupational Safety and Health Administration)
- SOX Section 806 complaints (180 days deadline)
- OSHA Section 11(c) complaints (30 days deadline)
- Various environmental and transportation whistleblower statutes

☐ SEC (Securities and Exchange Commission)
- Dodd-Frank securities law violations (6 years statute of limitations)

☐ DOL Administrative Review Board
- Appeals from OSHA determinations

☐ Federal Court
- FCA anti-retaliation claims (3 years statute of limitations)
- De novo actions after OSHA proceedings

☐ State Agency
- State whistleblower protection agencies
- State labor departments

I. COMPLAINANT INFORMATION

A. Personal Information

Full Legal Name: _________________________________

Also Known As (if applicable): _________________________________

Current Address:

Street: _________________________________

City: _________________________________

State: _________________ ZIP: _________________

Mailing Address (if different):

_____________________________________________________________________________

Contact Information:

Primary Phone: _________________________________

Alternate Phone: _________________________________

Email: _________________________________

Preferred Method of Contact: ☐ Phone ☐ Email ☐ Mail

Best Times to Contact: _________________________________

B. Employment Status

Current Employment Status:
☐ Currently employed by Respondent
☐ Terminated by Respondent
☐ Resigned from Respondent
☐ On leave from Respondent
☐ Other: _________________________________

If no longer employed, last day of employment: _________________________________

II. RESPONDENT (EMPLOYER) INFORMATION

A. Primary Respondent

Company/Organization Name: _________________________________

Type of Entity:
☐ Corporation
☐ LLC
☐ Partnership
☐ Government Agency
☐ Non-Profit
☐ Other: _________________________________

Address:

Street: _________________________________

City: _________________________________

State: _________________ ZIP: _________________

Phone: _________________________________

Website: _________________________________

Industry: _________________________________

Number of Employees:
☐ 1-14
☐ 15-100
☐ 101-500
☐ 501-1000
☐ Over 1000

Is the company publicly traded?
☐ Yes - Stock Symbol: _____________
☐ No

B. Additional Respondents (if applicable)

Individual Respondent 1:

Name: _________________________________

Title/Position: _________________________________

Relationship to Complainant: _________________________________

Role in Retaliation: _________________________________

Individual Respondent 2:

Name: _________________________________

Title/Position: _________________________________

Relationship to Complainant: _________________________________

Role in Retaliation: _________________________________

III. EMPLOYMENT DETAILS

A. Position Information

Job Title: _________________________________

Department: _________________________________

Location/Work Site: _________________________________

Date of Hire: _________________________________

Date of Termination/Adverse Action: _________________________________

Employment Type:
☐ Full-time
☐ Part-time
☐ Contract
☐ Temporary
☐ Independent Contractor

B. Compensation

Salary/Wage Rate: $_________________ per _________________

Benefits:
☐ Health Insurance
☐ Retirement/401(k)
☐ Paid Time Off
☐ Bonus Eligibility
☐ Stock Options
☐ Other: _________________________________

C. Supervisory Chain

Immediate Supervisor:

Name: _________________________________

Title: _________________________________

Department Head/Manager:

Name: _________________________________

Title: _________________________________

HR Representative:

Name: _________________________________

Title: _________________________________

IV. PROTECTED ACTIVITY

A. Type of Protected Whistleblowing Activity

Check all that apply:

☐ Reported violation of law to government agency
Agency: _________________________________
Date(s): _________________________________

☐ Reported violation of law internally to employer
To Whom: _________________________________
Date(s): _________________________________

☐ Refused to participate in illegal activity
Nature of Activity: _________________________________
Date(s): _________________________________

☐ Participated in government investigation
Agency: _________________________________
Date(s): _________________________________

☐ Testified or provided information in legal proceeding
Case/Matter: _________________________________
Date(s): _________________________________

☐ Filed qui tam/FCA complaint
Date Filed: _________________________________
Case No.: _________________________________

☐ Reported securities law violations
Date(s): _________________________________

☐ Reported safety/health violations
Date(s): _________________________________

☐ Other protected activity:
_________________________________

B. Description of Protected Activity

Provide a detailed description of the protected whistleblowing activity:

What violation(s) did you report or refuse to participate in?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

To whom did you report the violation(s)?

_____________________________________________________________________________

When did you report (include all dates)?

_____________________________________________________________________________

How did you report (verbal, written, email, hotline, etc.)?

_____________________________________________________________________________

What response, if any, did you receive?

_____________________________________________________________________________

_____________________________________________________________________________

C. Evidence of Protected Activity

Documentary Evidence:

☐ Written complaints (emails, letters, memos)
☐ Hotline reports/confirmation numbers
☐ Government agency filings
☐ Meeting notes
☐ Text messages
☐ Other: _________________________________

Witnesses to Protected Activity:

V. ADVERSE/RETALIATORY ACTIONS

A. Type of Adverse Action

Check all retaliatory actions taken against you:

☐ Termination/Discharge
Date: _________________________________
Stated Reason: _________________________________

☐ Demotion
From Position: _____________ To Position: _____________
Date: _________________________________

☐ Suspension
Dates: __________ to __________
With/Without Pay: _________________________________

☐ Reduction in Pay/Benefits
Amount/Description: _________________________________
Date: _________________________________

☐ Denial of Promotion
Position Denied: _________________________________
Date: _________________________________

☐ Negative Performance Review
Date: _________________________________
Prior Review History: _________________________________

☐ Reassignment/Transfer
From: _____________ To: _____________
Date: _________________________________

☐ Reduction in Hours
From: _______ hours to _______ hours
Date: _________________________________

☐ Hostile Work Environment/Harassment
Nature: _________________________________

☐ Threats
Nature: _________________________________
By Whom: _________________________________

☐ Blacklisting
Description: _________________________________

☐ Immigration-Related Threats
Nature: _________________________________

☐ Other Adverse Actions:
_________________________________

B. Timeline of Retaliation

C. Detailed Description of Retaliation

Provide a detailed narrative of the retaliatory actions:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

D. Causal Connection

Describe the connection between your protected activity and the retaliation:

Temporal Proximity:
Time between protected activity and adverse action: _________________________________

Evidence of Retaliatory Motive:

☐ Direct statements by management
☐ Timing of adverse action
☐ Departure from normal procedures
☐ Disparate treatment compared to others
☐ Pretextual reasons given
☐ Other: _________________________________

Describe the evidence showing the adverse action was because of your protected activity:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

VI. EMPLOYER'S STATED REASONS

A. Reason Given for Adverse Action

What reason(s) did the employer give for the adverse action?

_____________________________________________________________________________

_____________________________________________________________________________

B. Why the Stated Reason is Pretextual

Explain why you believe the employer's stated reason is false or pretextual:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Evidence supporting pretext:

☐ Prior positive performance reviews
☐ No prior discipline for similar conduct
☐ Others engaged in same conduct without discipline
☐ Timing inconsistent with stated reason
☐ Shifting explanations
☐ Other: _________________________________

VII. DAMAGES AND RELIEF SOUGHT

A. Economic Damages

Lost Wages:

Last Salary/Wage: $_________________ per _________________

Date of Last Paycheck: _________________________________

Lost Wages to Date: $__________________

Estimated Future Lost Wages: $__________________

Lost Benefits:

Health Insurance Value: $_________________ per _________________

Retirement Contributions Lost: $__________________

Other Benefits Lost: $__________________

Job Search Expenses:

_____________________________________________________________________________

Other Economic Damages:

_____________________________________________________________________________

TOTAL ECONOMIC DAMAGES: $__________________

B. Non-Economic Damages

☐ Emotional distress
☐ Damage to reputation
☐ Humiliation
☐ Mental anguish
☐ Physical symptoms (describe): _________________________________
☐ Medical treatment required: _________________________________

C. Relief Requested

Check all relief sought:

☐ Reinstatement to former position

☐ Front Pay (if reinstatement not feasible)

☐ Back Pay with interest

☐ Compensatory Damages for emotional distress

☐ Punitive Damages (where available)

☐ Attorney's Fees and Costs

☐ Expungement of negative information from personnel file

☐ Neutral Reference

☐ Posting of Notice regarding employee rights

☐ Other Relief:
_________________________________

VIII. PRIOR COMPLAINTS AND PROCEEDINGS

A. Internal Complaints

Did you file an internal complaint or grievance?

☐ No
☐ Yes

If yes:
Date Filed: _________________________________
To Whom: _________________________________
Outcome: _________________________________

B. Other Agency Complaints

Have you filed a complaint with any other agency about this matter?

☐ No
☐ Yes

If yes, provide details for each:

Agency: _________________________________
Date Filed: _________________________________
Case/Charge Number: _________________________________
Status: _________________________________

C. Court Proceedings

Have you filed a lawsuit about this matter?

☐ No
☐ Yes

If yes:
Court: _________________________________
Case Number: _________________________________
Status: _________________________________

IX. STATUTE OF LIMITATIONS COMPLIANCE

A. Key Dates

Date of Protected Activity: _________________________________

Date of First Adverse Action: _________________________________

Date You First Became Aware of Retaliation: _________________________________

Date of This Complaint: _________________________________

B. Applicable Statute of Limitations

Identify the applicable statute and deadline:

X. WITNESSES AND EVIDENCE

A. Witnesses

B. Documentary Evidence

XI. CERTIFICATION AND SIGNATURE

I, _________________________, hereby certify under penalty of perjury that:

1. I have read this Complaint and the information provided is true and accurate to the best of my knowledge, information, and belief.

2. I understand that providing false information may subject me to penalties.

3. I authorize the investigating agency to review my employment records as necessary for this investigation.

4. I agree to cooperate fully with any investigation of this Complaint.

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

STATE-SPECIFIC NOTES

California

California Labor Code § 1102.5 provides broad whistleblower protections. Employees may file complaints with the California Labor Commissioner or file a civil lawsuit. California law protects reports to supervisors or government agencies. Statute of limitations is 3 years. As of January 1, 2025, employers must post a whistleblower rights notice.

New York

New York Labor Law § 740 (as amended in 2022) provides expansive protections covering violations of any law, rule, or regulation. Protections extend to former employees and independent contractors. Statute of limitations is 2 years. Employers must post notice of employee rights.

Texas

Texas Whistleblower Act (Tex. Gov. Code Ch. 554) protects only public employees. Private sector employees have limited protections. Public employees must first exhaust internal grievance procedures. Statute of limitations is 90 days for filing suit after exhausting remedies.

Florida

Florida Whistleblower Act (Fla. Stat. § 448.102) covers private employers with 10+ employees. Public employees are covered under Fla. Stat. § 112.3187. Effective July 1, 2025, expanded protections for private sector workers. Public employees must file with Florida Commission on Human Relations within 60 days.

FILING INSTRUCTIONS BY AGENCY

OSHA Complaints (SOX, Section 11(c), etc.)

Online: www.osha.gov/whistleblower/wbcomplaint

By Mail/Fax/Email: Contact your Regional OSHA Office

Phone: 1-800-321-OSHA (6742)

Requirements:
- Must file within applicable deadline (30-180 days depending on statute)
- Complaints may be verbal or written
- Include your contact information and employer information
- Describe protected activity and adverse action

SEC Complaints (Dodd-Frank)

Online: www.sec.gov/tcr

Form: TCR (Tip, Complaint, or Referral)

Requirements:
- Must submit in writing for retaliation protection
- May submit anonymously if represented by counsel
- Include description of securities law violation
- File civil action within 6 years of retaliation

DOL Administrative Complaints

Address complaints to: Office of Administrative Law Judges

Appeals from OSHA: Administrative Review Board

Federal Court (FCA Retaliation)

Requirements:
- File civil complaint in federal district court
- 3-year statute of limitations
- No administrative exhaustion required

CHECKLIST BEFORE FILING

☐ Confirmed filing deadline for applicable statute(s)
☐ Gathered all relevant documents
☐ Identified all witnesses
☐ Documented timeline of events
☐ Calculated economic damages
☐ Reviewed employer's stated reasons for adverse action
☐ Considered consulting with an attorney
☐ Made copies of all documents for your records
☐ Completed all sections of this complaint form

This template is provided for educational purposes only and does not constitute legal advice. Whistleblower retaliation claims have strict deadlines that vary by statute. Failure to file within the applicable deadline may bar your claim. Consult with an attorney experienced in whistleblower law immediately.