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IOSHA Whistleblower Complaint Form

A whistleblower complaint relates to alleged action taken against an employee in retaliation for engaging in activity protected by the whistleblower law that Iowa OSHA enforces.

For example, if an employer retaliates against an employee for making a safety and health complaint, such retaliation violates the act. A whistleblower complaint may prompt an investigation into whether an employer retaliated against an employee for engaging in protected activity under whistleblower laws.

If a whistleblower complaint is filed with Iowa OSHA that includes allegations of safety and health hazards, that portion of the complaint will be referred to IOSHA safety and health enforcement staff for possible inspection.

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Is your complaint related to workplace safety and/or health?

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Is your complaint related to unpaid wages?

Complaints Regarding Unpaid Wages

If you believe you are owed wages not exceeding $6,500, you can file a wage claim with DIAL's Wage and Hour Unit.

If your claim has to do with federal minimum wage or overtime, you may contact the U.S. Department of Labor, Wage & Hour Division at 515.284.4625.

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Is your complaint related to retaliation (including threats, interrogation, surveillance, discipline, or termination) for engaging in union organization or protected concerted activity?

Complaints Regarding Union or Protected Activity

If you would like to report an incident of employer retaliation related to threats, interrogation, surveillance, discipline, or termination for engaging in union organization or protected concerted activity you will need to report this to the National Labor Relations Board.

National Labor Relations Board
Region 18
Federal Office Building
212 Third Avenue South, Suite 200
Minneapolis, Minn. 55401
612.348.1757
nlrb.gov

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Is your complaint related to employer retaliation because of a personal characteristic such as race, skin color, national origin, sex/sexual orientation, gender identity, disability, religion, age, or pregnancy?

Civil Rights and Equal Opportunity Complaints

If you would like to report an incident of employer retaliation or discrimination because of a personal characteristic (e.g., race, skin color, national origin, sex/sexual orientation, gender identity, disability, religion, age, or pregnancy), you will need to report this to the Iowa Civil Rights Commission.

File a complaint about this type of retaliation or discrimination with the Iowa Civil Rights Commission.

Iowa Civil Rights Commission
6200 Park Avenue, Suite 100
Des Moines, Iowa 50321-1270
515.281.4121 or 800.457.4416
icrc.iowa.gov

U.S. Equal Employment Opportunity Commission
Reuss Federal Plaza
310 West Wisconsin Avenue, Suite 500
Milwaukee, Wis 53203-2292
800.669.4000
eeoc.gov

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As you have indicated this whistleblower complaint is not about workplace health or safety, you don't need to complete this form.

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Return to DIAL website.

Is your complaint regarding retaliation for reporting any of the following?

Workplace safety and/or health issues or other laws covered by OSHA

Reporting a work-related injury or illness

Filing a complaint or reporting regulatory violations to OSHA or any other federal government or regulatory agency other than the Equal Employment Opportunity Commission or the National Labor Relations Board

Refusing to perform a task the employee believes is dangerous or illegal

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First Name

Last Name

Phone Number

Address 1

Address 2

City

State

ZIP Code

County

Date Hired

(Click twice on the month and year at the top of the calendar to change the year.)

Action taken against employee

Date action was taken

(Click twice on the month and year at the top of the calendar to change the year.)

Final Wage Earned

Job Title

Department

Immediate Supervisor

Employer Name

Employer Address 1

Employer Address 2

Employer City

Employer State

Employer ZIP Code

Employer Phone Number

Company Official/Title

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Additional Questions

Do you belong to a union?

Name of union

Number of union members

Union Local #

Union Address 1

Union Address 2

Union City

Union State

Union ZIP Code

Steward

Business Agent

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Narrative Response

Company Reason

Perceived Reason

Was action taken against other employees for the same reason?

Other Employees Affected

Have you applied for unemployment insurance?

Date of Application

(Click twice on the month and year at the top of the calendar to change the year.)

Have you ever refused to perform any work?

Explanation

Have you ever received discipline (warnings or reprimands)?

Explanation of discipline

Have you ever complained to the company?

Have you ever complained to any regulatory agency?

Name of agency

Agency Phone Number

Date of Complaint

Reason for the complaint?

Did company officials know of your complaint?

Who knew and how?

Did any other employee(s) know about your complaint?

Name(s), address(es), and phone number(s)

Witnesses/Details?

Detailed account

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This form contains facts that are true and correct to the best of my knowledge and belief.

I understand that Iowa Code 88.14(7) makes it a crime to knowingly make a false statement, representation, or certification in any application, record, report, plan, or other document.

I agree

I authorize the following person to release to DIAL/IOSHA copies of my personnel file, medical records, and any other requested documentation .

I agree

I do not agree

Sign Here

First Name

Last Name

Choose how to sign

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.