Form WSD-1.398 "Complaint Form" - Hawaii

What Is Form WSD-1.398?

This is a legal form that was released by the Hawaii Department of Labor & Industrial Relations - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2013;
  • The latest edition provided by the Hawaii Department of Labor & Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WSD-1.398 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Labor & Industrial Relations.

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Download Form WSD-1.398 "Complaint Form" - Hawaii

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STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
WAGE STANDARDS DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 340, Honolulu, Hawaii 96813
INSTRUCTION SHEET FOR WSD-1.398 COMPLAINT FORM
Chapter 398, Family Leave Law
Instructions
Note: For a family leave complaint, you must file within 90 days of either: (1) the date of the alleged violation, or (2) the
date you learned of the alleged violation.
Please completely fill out the WSD-1.398 Complaint Form.
Please type or print legibly. Read all instructions before completing the form. If you have any questions, call the nearest office
at the number listed below.
WSD-1.398 Complaint Form
Note: A copy of your complaint will be given to the employer.
Page 1 of 2:
Items 1 through 9:
Provide information pertaining to yourself.
Items 10 through 14:
Provide information about the employer you are filing a complaint against.
Items 15 through 24:
Provide information about the nature of your complaint.
Page 2 of 2:
Statement of facts:
(a) Briefly state the alleged violation.
(b) Describe how the employer committed the alleged violation by providing a brief summary of the pertinent
instances or examples which support your allegation.
Verification and Signature:
Your complaint must be verified by an authorized Department of Labor and Industrial Relations representative.
You will be required to produce identification. If you mail your complaint, it must be signed before a notary
public.
Check box if complainant is under 18 years old. If legal action becomes necessary, a parent or legal guardian
must sign an assignment.
IMPORTANT: Report any change of address or telephone number. If we are unable to contact you, your case will be closed.
The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the
completed form accordingly. Please remember to sign and date the form before submitting it.
Delivery Information
Delivery by U.S. Mail or In Person. Complaints may not be filed by fax.
Department of Labor and Industrial Relations
Wage Standards Division
,
Oahu
Phone: (808) 586 - 8777
830 Punchbowl Street, Rm. 340; Honolulu, HI 96813
Hilo
State Building, 75 Aupuni Street; Rm. 108; Hilo, HI 96720
Phone: (808) 974 - 6464
Kauai
3060 Eiwa Street; Rm. 202; Lihue, HI 96766
Phone: (808) 274 - 3351
Phone: (808) 984 - 2075
Maui
2264 Aupuni Street; Wailuku, HI 96793
West Hawaii
Post Office Building; P.O. Box 49; Kealakekua, HI 96750
Phone: (808) 322 - 4808
(Kona)
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
Print Form
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
WAGE STANDARDS DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 340, Honolulu, Hawaii 96813
INSTRUCTION SHEET FOR WSD-1.398 COMPLAINT FORM
Chapter 398, Family Leave Law
Instructions
Note: For a family leave complaint, you must file within 90 days of either: (1) the date of the alleged violation, or (2) the
date you learned of the alleged violation.
Please completely fill out the WSD-1.398 Complaint Form.
Please type or print legibly. Read all instructions before completing the form. If you have any questions, call the nearest office
at the number listed below.
WSD-1.398 Complaint Form
Note: A copy of your complaint will be given to the employer.
Page 1 of 2:
Items 1 through 9:
Provide information pertaining to yourself.
Items 10 through 14:
Provide information about the employer you are filing a complaint against.
Items 15 through 24:
Provide information about the nature of your complaint.
Page 2 of 2:
Statement of facts:
(a) Briefly state the alleged violation.
(b) Describe how the employer committed the alleged violation by providing a brief summary of the pertinent
instances or examples which support your allegation.
Verification and Signature:
Your complaint must be verified by an authorized Department of Labor and Industrial Relations representative.
You will be required to produce identification. If you mail your complaint, it must be signed before a notary
public.
Check box if complainant is under 18 years old. If legal action becomes necessary, a parent or legal guardian
must sign an assignment.
IMPORTANT: Report any change of address or telephone number. If we are unable to contact you, your case will be closed.
The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the
completed form accordingly. Please remember to sign and date the form before submitting it.
Delivery Information
Delivery by U.S. Mail or In Person. Complaints may not be filed by fax.
Department of Labor and Industrial Relations
Wage Standards Division
,
Oahu
Phone: (808) 586 - 8777
830 Punchbowl Street, Rm. 340; Honolulu, HI 96813
Hilo
State Building, 75 Aupuni Street; Rm. 108; Hilo, HI 96720
Phone: (808) 974 - 6464
Kauai
3060 Eiwa Street; Rm. 202; Lihue, HI 96766
Phone: (808) 274 - 3351
Phone: (808) 984 - 2075
Maui
2264 Aupuni Street; Wailuku, HI 96793
West Hawaii
Post Office Building; P.O. Box 49; Kealakekua, HI 96750
Phone: (808) 322 - 4808
(Kona)
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
WAGE STANDARDS DIVISION
WSD-1.398 COMPLAINT FORM
Chapter 398, Family Leave Law
Complainant Information: Please print or type
Name
(Last,
First
Middle Initial)
1.
2. Last four digits of Social Security No.
Mr.
Mrs.
Ms.
XXX-XX-
Address
City
State
Zip Code
3.
Phone
Cell Phone
Email Address
4.
(
)
(
)
Type and Title of Work Performed
6. Employment Status
5.
Quit
Discharged
Current Employee of Employer Named Below
If No Longer Employed, Reason
7.
9. Union Membership
8.
Date(s)
Yes
No
From:
To:
Period of Employment :
If yes, Name of Union:
Employer Information:
10. Business Name
11. Address
City
State
Zip Code
12. Phone
Fax
Cell
(
)
(
)
(
)
13. Name and Title of Owner or Person in Charge
14. Nature of Business
Complaint Information
15. Qualifying reason you requested family leave:
Birth of a child
To care for a child, spouse, reciprocal beneficiary, or parent with a serious health condition
Adoption of a child
16. Alleged violation(s) - Check those that apply and explain:
Refusal to properly grant family leave
Denial of use of accrued and available sick leave
Refusal to restore same or equivalent position
Other
Failure to maintain or restore equivalent benefits
Refusal to authorize substitution of accrued paid leave (such as vacation) upon employee election
17. Explanation of circumstances and related details of the alleged violation(s) above:
18.
19.
Date of discovery of alleged violation:
Date of alleged violation:
20. If your employer required certification for family leave, was it
21. Type of employer:
Private Sector
provided?
Yes
No
Public Sector
State
County
22.
Approximately how many employees does the employer have?
23.
Months of consecutive employment at the time of violation:
24.
Were you covered by a collective bargaining agreement?
FOR OFFICE USE ONLY
Law
ICB
Date Received
CS
DOL #:
IS1
IS2
Taken by
HB
No.
H
K
M
WH
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
WSD-1.398 COMPLAINT FORM
Page 2 of 2
Statement of Facts (Briefly explain pertinent facts of the alleged violation):
I swear or affirm that I have read this complaint, and that the information and statements are true to the best of my knowledge
and belief. I authorize the Director of Labor and Industrial Relations or a departmental representative to collect and receive, on
my behalf, payments made on my complaint.
Note: Do not date or sign unless in the presence of an authorized DLIR representative or a notary public.
Date:
Signature of Complainant:
Check if under 18 years old
FOR OFFICE USE ONLY
VERIFIED BY:
Authorized DLIR Representative
Date
FOR NOTARY PUBLIC:
STATE OF HAWAII
)
) SS.
___________ COUNTY OF ___________
)
On this ________ day of _________, 20__, before me personally appeared
______________________________________
__________________________ and _____________________, to me known to be the
(Signature)
person(s) described herein, and who, being duly sworn, did say that he/she/they is/are
Notary Public, State of Hawaii
the said ____________________ named in the foregoing instrument, and that
My commission expires: _________________
he/she/they executed said instrument as his/her/their own free act and deed.
Document Date:
____________________
# of Pages: _________
Printed Notary Name:
_____________________________
______________ Circuit
Document Description:
_______________________________________________________
_____________________________________________________________________________
___________________________________________
_____________________
Notary Signature
Date
(Stamp or Seal)
NOTARY CERTIFICATION
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
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