Minimum Wage Program Complaint You must have JavaScript enabled to use this form. Items marked with an asterisk ( * ) are required. Contact Information Name Mailing Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Email (if you do not have an email, enter N/A) Phone Best way to contact you Phone Mail Email What is your preferred language? Do you required translation and/or interpretation services? Yes No What are you contacting us about? Minimum Wage Earned Sick Leave Traffic Control Worker Minimum Wage Live Event Worker Safety Ordinance Grocery Pricing Transparency Ordinance Unsure/Other Unsure/Other (please explain) Business/Employer Information Name of Business Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Supervisor Name Supervisor Job Title Supervisor Email Supervisor Phone Your Relationship to the Business or Situation Current employee Former employee Worker advocate/organization Witness and/or coworker Union representative Customer or shopper (grocery store complaints) Other Other (please explain) Anonymous Reporting Do you wish to remain anonymous? Yes - I wish to remain anonymous No - You may contact me If you choose to remain anonymous, OLSE will not be able to provide updates on the status of your complaint or request additional information. Wage Complaints Complete this section if your complaint involves earned sick leave, minimum wage, or other wage violations Job Title Hourly Wage or Rate of Pay Do you receive earned sick leave? Yes No Not sure Please provide details about the alleged violations and your work conditions. Include information such as dates, place of work, witnesses, and any documentation that may support your complaint. Retaliation Complaints Have you experienced retaliation from this employer? Yes No If yes, please describe the retaliation (for example: termination, reduced hours, threats, discipline, or other actions). Grocery Pricing Transparency Ordinance Complaints Date and approximate time of alleged violation Date and approximate time of alleged violation: Date Date and approximate time of alleged violation: Time Alleged Digital Discount Issue Mobile or smartphone application discount Website-only pricing QR code discount Email or text-based promotion Other Other (please explain) Brief description of what happened Product Information Leave this field blank
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