Form SCF-4 "Complaint of Discrimination" - New Jersey

What Is Form SCF-4?

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

Form Details:

  • Released on May 1, 2013;
  • The latest edition provided by the New Jersey Department of Labor & Workforce Development;
  • 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 printable version of Form SCF-4 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Labor & Workforce Development.

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Download Form SCF-4 "Complaint of Discrimination" - New Jersey

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Department of Labor and Workforce Development
COMPLAINT OF DISCRIMINATION
Office of Special Compensation Funds
N.J.S.A. 34:15-39.1 et seq.
P O Box 399
Trenton, New Jersey 08625-0399
SCF-4 (R 05-13)
The New Jersey Workers’ Compensation Law (N.J.S.A. 34:15-1 et seq.) provides that it shall be unlawful for an employer to discharge or otherwise
discriminate against an employee because that employee has filed or has attempted to file a claim for workers’ compensation benefits or has testified
or has planned to testify in any proceeding before the Division of Workers’ Compensation. This complaint is to be completed by the employee who
alleges such discrimination
.
Please Note: All applicable information must be completed on this complaint and any and all relevant evidence supporting the complaint
must be attached. The complaint must be signed by the complainant and notarized. The complaint and attachments must be submitted
in duplicate (original and one copy).
01. Your Name:
:
02. Your Social Security Number
(Last)
(First)
(Middle)
03.
:
Your Complete Home Address
(Street Number – No PO Boxes)
(City)
(County)
(State)
(Zip Code)
:
05. If Employed, Your Daytime Telephone Number:
04 Your Telephone Number
a. □ I feel that I was discriminated against for filing or attempting to file a workers’ compensation claim.
06. Nature of Complaint:
b. □ I feel that I was discriminated against for my testimony or plan to testify in a workers’ compensation matter.
(Check One):
:
08. New Jersey Employer Identification Number (if known):
07. Name of Employer
09. Complete Employer Address:
(Street Number – No PO Boxes)
(City)
(County)
(State)
(Zip Code)
10. Employer Agent Name:
11. Employer Agent Telephone Number:
COMPLETE ITEMS #12 THROUGH #20 ONLY IF YOU HAVE CHECKED BOX ‘a” IN ITEM #06, ABOVE
12. Name of Employer’s Workers’ Compensation Insurance Carrier:
13. Have you filed a claim with this carrier?
□ No
□ Yes, Claim#:______________________________
14. Have you filed a claim with the NJ Division of Workers’ Compensation?
15. Date of Accident/Last Exposure:
□ No
□ Yes, Claim Petition#:____________________
16. Your Occupation at Time of Accident/Last Exposure:
17. Nature of Your Disability:
18. Your Gross Weekly Wages at Time of Accident/Last Exposure:
19. You Job Duties at Time of Accident/Last Exposure:
20. Are You Currently Able To Fully Perform Those Duties?
□ Yes
□ No*
*If you have checked “No” for Item #20, indicating that you are not currently able to fully perform the duties of your employment, your remedies
under the law are limited. While the complaint can be processed and penalties assessed against the employer, if found to have committed prohibited
acts, the law provides that no reinstatement to employment or compensation for lost wages may be ordered for any period during which you are not
fully able to perform the duties of your employment.
(CONTINUED ON BACK)
Department of Labor and Workforce Development
COMPLAINT OF DISCRIMINATION
Office of Special Compensation Funds
N.J.S.A. 34:15-39.1 et seq.
P O Box 399
Trenton, New Jersey 08625-0399
SCF-4 (R 05-13)
The New Jersey Workers’ Compensation Law (N.J.S.A. 34:15-1 et seq.) provides that it shall be unlawful for an employer to discharge or otherwise
discriminate against an employee because that employee has filed or has attempted to file a claim for workers’ compensation benefits or has testified
or has planned to testify in any proceeding before the Division of Workers’ Compensation. This complaint is to be completed by the employee who
alleges such discrimination
.
Please Note: All applicable information must be completed on this complaint and any and all relevant evidence supporting the complaint
must be attached. The complaint must be signed by the complainant and notarized. The complaint and attachments must be submitted
in duplicate (original and one copy).
01. Your Name:
:
02. Your Social Security Number
(Last)
(First)
(Middle)
03.
:
Your Complete Home Address
(Street Number – No PO Boxes)
(City)
(County)
(State)
(Zip Code)
:
05. If Employed, Your Daytime Telephone Number:
04 Your Telephone Number
a. □ I feel that I was discriminated against for filing or attempting to file a workers’ compensation claim.
06. Nature of Complaint:
b. □ I feel that I was discriminated against for my testimony or plan to testify in a workers’ compensation matter.
(Check One):
:
08. New Jersey Employer Identification Number (if known):
07. Name of Employer
09. Complete Employer Address:
(Street Number – No PO Boxes)
(City)
(County)
(State)
(Zip Code)
10. Employer Agent Name:
11. Employer Agent Telephone Number:
COMPLETE ITEMS #12 THROUGH #20 ONLY IF YOU HAVE CHECKED BOX ‘a” IN ITEM #06, ABOVE
12. Name of Employer’s Workers’ Compensation Insurance Carrier:
13. Have you filed a claim with this carrier?
□ No
□ Yes, Claim#:______________________________
14. Have you filed a claim with the NJ Division of Workers’ Compensation?
15. Date of Accident/Last Exposure:
□ No
□ Yes, Claim Petition#:____________________
16. Your Occupation at Time of Accident/Last Exposure:
17. Nature of Your Disability:
18. Your Gross Weekly Wages at Time of Accident/Last Exposure:
19. You Job Duties at Time of Accident/Last Exposure:
20. Are You Currently Able To Fully Perform Those Duties?
□ Yes
□ No*
*If you have checked “No” for Item #20, indicating that you are not currently able to fully perform the duties of your employment, your remedies
under the law are limited. While the complaint can be processed and penalties assessed against the employer, if found to have committed prohibited
acts, the law provides that no reinstatement to employment or compensation for lost wages may be ordered for any period during which you are not
fully able to perform the duties of your employment.
(CONTINUED ON BACK)
(CONTINUED FROM FRONT)
COMPLETE ITEMS #21 THROUGH #26 ONLY IF YOU HAVE CHECKED “b” IN ITEM #06, ABOVE
21. Full Name of Petitioner in Workers’ Compensation Case
22. Claim Petition Number:
23. Did You Testify in this Case?
24. Date and Location of Testimony:
□ No
□ Yes (If Yes, Complete Item #24)
25. Are You Scheduled to Testify in this Case?
26. Scheduled Date and Location of Testimony:
□ No
□ Yes (If Yes, Complete Item #26)
29. If Currently Employed, Employer’s Name and Address:
27. Date of Termination or Other Personnel Action:
28. Reason Given by Employer for Termination or Other Action:
30. If Employed, Your Current Gross Weekly Wages:
31. State here and/or attach to this complaint any and all relevant evidence supporting your allegation of discrimination:
State of New Jersey, County of _____________________________________________
_______________________________________________________, of full age, being duly sworn according to law, on my oath depose and say:
That I am the complainant named in the foregoing complaint; that I have read the same; and that the matter and things therein set forth are
true according to the best of my knowledge and belief.
_____________________________________________
(Complainant’s Signature)
__________________________________________________________________
Subscribed and sworn before me on this _______ day of ___________________________, _________.
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