Instructions for Employment Retaliation (Whistleblower) Questionnaire/Affidavit Form

Form 54049 (73kb pdf)

If you believe that you have been unlawfully retaliated against regarding your employment rights and would like the North Dakota Department of Labor's assistance, you may complete and return the Employment Retaliation (Whistleblower) Intake Questionnaire. The intake questionnaire provides the department with information to determine if your concerns fall within the scope of our authority.

The department is able to accept complaints of unlawful retaliation on behalf of: a) an employee or a person acting on behalf of an employee who, in good faith, reports a violation of federal, state, or local law, ordinance, regulation, or rule to an employer, a governmental body, or a law enforcement official; b) an employee who has been requested by a public body or official to participate in an investigation, hearing, or inquiry; or c) an employee who refuses an employer's order to perform an action that the employee believes violates local, state, or federal law, ordinance, rule, or regulation (the employee must have an objective basis in fact for that belief and shall inform the employer that the order is being refused for that reason).

Please answer the items on the questionnaire completely and specifically so that we can fully assess your situation. Please print or type your answers and use additional sheets of paper if necessary. Incomplete questionnaires will be returned for completion. Copies of any records or documents you have that support your claim should also be submitted with the completed questionnaire.

If the department determines that it does have a legal basis to proceed, it will generate a formal complaint, which will be mailed to you. You will be asked to review the complaint, sign it, and return it to the Department of Labor. The department may attempt to obtain voluntary compliance through informal advice, negotiation, or conciliation.

If the department determines that it does not have a legal basis to proceed, you will be notified in writing and given the opportunity to provide further information if applicable. Please be advised that there are many unfair acts that do not constitute unlawful retaliation.

Timeliness is important when filing your concerns. There is a 300-day limitation, from the date of the alleged discriminatory act, within which the signed formal complaint must be returned to the department. Keep in mind that the intake questionnaire must be submitted in time to allow the department to assess the initial information, acquire any additional information necessary, and process a formal complaint before the time limit expires.

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