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State Form Number (SFN) 54049

Employment Retaliation (Whistleblower) Questionnaire/Affidavit Form

• SFN 54049 Form (pdf)

Instructions for SFN 54049

Please answer the items on the questionnaire completely and specifically so that we can fully assess your situation. Please type or write your answers legibly, using additional 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.