Document Number: ERD-13521-E
Description: This form should be used to file a complaint of discharge, retaliation or discrimination under any of the five laws regarding employment protection for people who report elder abuse or certain other similar concerns, or cooperate with government agencies regulating the health care industry.
Comments: This form must be signed by Complainant or authorized representative.
Content Contact: Equal Rights Information
ERD-13521-E (Electronic Version - Word/118 KB)
ERD-13521 (Print Version - pdf/31 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.