Fillable COMPLAINT FORM OFFICE OF LABOR STANDARDS (City of Chicago)

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COMPLAINT FORM OFFICE OF LABOR STANDARDS (City of Chicago)

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What is your complaint about? (check all that apply)
Minimum Wage
Paid Sick Leave
What is your complaint?
OFFICE OF LABOR STANDARDS
COMPLAINT FORM
INSTRUCTIONS
OFFICE USE
Date Received:
Processed By:
CSR#:
PLEASE CONTINUE TO NEXT PAGE
(NEXT PAGE MUST BE COMPLETED AND SIGNED)
CITY OF CHICAGO
DEPARTMENT OF BUSINESS AFFAIRS
AND CONSUMER PROTECTION
121 N. LaSalle St., Room 805
Chicago, IL 60602
Tel. 312-744-2211
www.chicago.gov/laborstandards
Business Name:
Type of Business:
Address:
City State Zip Code
Phone Number:
COMPLAINT INFORMATION
• Complete this form to the fullest extent possible
• Sign and date the form
• Upon receipt of the form, the Office of Labor Standards will call upon you for an intake
interview to gather further information
In what language do you prefer to communicate with us?
Fair Workweek (scheduling)
Anti-Retaliation (retaliation related to COVID-19)
READ THE FOLLOWING BEFORE SIGNING:
The Department of Business Affairs and Consumer Protection enforces laws
governed by the City of Chicago Municipal Code to protect consumers and
businesses from unfair and deceptive practices. I understand that if I have any
questions regarding this complaint and my legal rights I should contact a private
attorney. I affirm that the above stated information is true and accurate to the best
of my ability.
Your electronic signature is the same as a handwritten signature for the purposes of
legal effect, enforceability, and admissibility.
Signature Date
COMPLAINANT INFORMATION
CSR # ________________________________________
v.06.2020 OFFICE OF LABOR STANDARDS COMPLAINT FORM
PLEASE SUBMIT BY MAIL, E-MAIL, OR FAX:
Mail to: Department of Business Affairs and Consumer Protection (BACP)
Attn: Office of Labor Standards
121 N. LaSalle St., Room 805
Chicago, IL 60602
or
E-mail to: BACPlaborstandards@cityofchicago.org
or
Fax to: 312.743.1841
Note: If you are faxing this form, please include a fax cover sheet
First Name: Last Name:
Your Phone Number:
Your E-Mail Address:
What is your job?
Are you an independent contractor?
How many people work alongside you for your employer?
Are you a member of a union?
Additional questions for Fair Workweek (scheduling) complaints.
Do you perform most of your work in building services, hotels,
healthcare, manufacturing, warehouse services, retail, or restaurants?
How much do you earn per hour (or in salary)? _______________________________________________
You may designate an alternate contact in the case that we are unable to reach you.
Alternate Contact Name:
Your relationship to the alternate contact:
Alternate Contact Phone Number:
Alternate Contact E-Mail Address:
Yes No
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COMPLAINT FORM OFFICE OF LABOR STANDARDS (City of Chicago)

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Completed 27 July 2021

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