Earned Sick and Safe Time Complaint Form
Do you work in Bloomington?:
*
Yes
No
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Name
Phone number:
Email (or mailing address, if preferred):
I am a:
Worker
Other
Workplace/Business Name:
Workplace/Business Address:
Occupation/Industry:
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Briefly describe what happened:
*
(who, what, when, and how)
Is the employer aware of the law?
Yes
No
Unsure
What is the best time to contact you?
8:00 AM to 12:00 PM
1:00 PM to 4:00 PM
Either
Other
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