Skip to main content Skip to navigation
Skip to main content

Healthcare Worker Complaint

Use this form to file a complaint for unfair labor practices by an acute care facility or hospital.

Is your complaint regarding issues occurring before March 15, 2022?

Violations

What is your complaint about? (check all that apply)
0 of 4000
Example: I have been asked to work without taking lunch breaks.

Employee Information

Format: XXX-XXX-XXXX
Mailing Address

Employer Information

Search for your hospital or healthcare facility in the search bar below. If your healthcare facility is not found then click the "Add New Facility" tab above to fill out information on your healthcare facility.

Fill out information on your hospital or healthcare facility below. Click the "Search Facility" tab to search for your healthcare facility instead.

Format: XXX-XXX-XXXX
Facility Mailing Address
Business Contact
Format: XXX-XXX-XXXX

Work Period

Provide as much information as possible. The more information we have, the faster we can investigate your complaint.

Date you began working for this employer

Date period of your complaint
Start Date

End Date

0 of 4000
Explain what your work schedule looks like (e.g. 9 A.M. to 5 P.M., Monday through Friday)
Is there a formal process at your facility or hospital for reporting violations within your organization?
Have you communicated your concerns about missing breaks or being forced to work overtime to your supervisor or HR?
Are there any specific reasons why breaks are missed or overtime is imposed (such as patient increase, staffing issues, or patient care emergencies)?

Supporting Documents

Complaint processing can happen faster when you upload supporting documents with this submission. Please do not include any sensitive patient information in your attachments.

Maximum file size: 20 MB
A maximum of (10) files can be uploaded with this submission.
    0 of 200

    Uploaded Files (10 Available Uploads Remaining)