Form F 700-199-000 Retaliation Complaint Form (Minimum Wage Act & Paid Sick Leave) - Washington

Form F700-199-000 is a Washington State Department of Labor and Industries form also known as the "Retaliation Complaint Form (minimum Wage Act & Paid Sick Leave)". The latest edition of the form was released in April 1, 2018 and is available for digital filing.

Download an up-to-date Form F700-199-000 in PDF-format down below or look it up on the Washington State Department of Labor and Industries Forms website.

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Retaliation Complaint Form
(Minimum Wage Act & Paid Sick Leave)
WAC 296-128-770
prohibits retaliation against employees for the exercise of employee rights provided by the Washington
Minimum Wage Act
(49.46
RCW) or its rules. Employee rights in the Washington Minimum Wage Act, which are protected
against retaliation include, but are not limited to: filing a wage complaint; exercising the right to paid sick leave, minimum
wage, overtime, tips and gratuities; or, testifying or intending to testify in any such proceeding related to any rights
provided under chapter
49.46
RCW. The Department of Labor & Industries investigates complaints of retaliation against
employees for the exercise of any of the employee rights found in
49.46
RCW or its rules.
What employer actions are considered retaliation?
Retaliation is defined in
WAC 296-128-770
and includes “any adverse action” taken or threatened by your
employer for the exercise of your protected rights. Examples include:
Denying the use of, or delaying payment for, paid sick leave, minimum wages, overtime wages, all
tips and gratuities, and all service charges except those itemized as not being paid to the employee.
Terminating, suspending, demoting, or denying the promotion of an employee.
Reducing the number of work hours for which the employee is scheduled.
Altering the employee’s preexisting work schedule.
Reducing the employee’s rate of pay.
Threatening to take, or taking action, based upon the immigration status of an employee or an
employee’s family member.
Other prohibited actions include:
An employer adopting or enforcing any policy that counts the legitimate use of paid sick leave as an
absence that may lead to or result in discipline by the employer against the employee.
An employer interfering with, restraining, or denying the exercise of any the employee rights found in
49.46
RCW.
Please note: the actions above are not an exhaustive list of actions, which can be considered
retaliation. Other adverse actions taken against you for the exercise of your protected rights may
also be investigated.
Retaliation complaints will not be accepted when:
You are part owner (including family owned) of the business, or a governing member of the business.
Your complaint is about unpaid vacation, holiday pay, severance pay, or reimbursement for
expenses including fuel.
Your complaint is about an employer not providing prescribed rest breaks and/or meals.
You are claiming retaliation against a business while working out of state for a non-Washington
employer.
Your complaint is about protected leave, missing wages or wages owed, prevailing wages, or an
issue of safety and/or health; however...
On separate complaint forms, L&I accepts for the following complaints:
Worker Rights Complaint form
(F700-148-000) for general wages, paid sick leave, or other worker rights
issues that are not protected under the Minimum Wage Act.
Protected Leave Complaint form
(F700-144-000) for family leave, family care, leave for victims of domestic
violence, sexual assault or stalking, spouse military leave, leave for voluntary firefights on the scene.
Prevailing Wage Complaint form
(F700-146-000) for wage complaints related to public works projects.
F700-199-000 Retaliation Complaint Form (Minimum Wage Act & Paid Sick Leave) 04-2018
Retaliation Complaint Form
(Minimum Wage Act & Paid Sick Leave)
WAC 296-128-770
prohibits retaliation against employees for the exercise of employee rights provided by the Washington
Minimum Wage Act
(49.46
RCW) or its rules. Employee rights in the Washington Minimum Wage Act, which are protected
against retaliation include, but are not limited to: filing a wage complaint; exercising the right to paid sick leave, minimum
wage, overtime, tips and gratuities; or, testifying or intending to testify in any such proceeding related to any rights
provided under chapter
49.46
RCW. The Department of Labor & Industries investigates complaints of retaliation against
employees for the exercise of any of the employee rights found in
49.46
RCW or its rules.
What employer actions are considered retaliation?
Retaliation is defined in
WAC 296-128-770
and includes “any adverse action” taken or threatened by your
employer for the exercise of your protected rights. Examples include:
Denying the use of, or delaying payment for, paid sick leave, minimum wages, overtime wages, all
tips and gratuities, and all service charges except those itemized as not being paid to the employee.
Terminating, suspending, demoting, or denying the promotion of an employee.
Reducing the number of work hours for which the employee is scheduled.
Altering the employee’s preexisting work schedule.
Reducing the employee’s rate of pay.
Threatening to take, or taking action, based upon the immigration status of an employee or an
employee’s family member.
Other prohibited actions include:
An employer adopting or enforcing any policy that counts the legitimate use of paid sick leave as an
absence that may lead to or result in discipline by the employer against the employee.
An employer interfering with, restraining, or denying the exercise of any the employee rights found in
49.46
RCW.
Please note: the actions above are not an exhaustive list of actions, which can be considered
retaliation. Other adverse actions taken against you for the exercise of your protected rights may
also be investigated.
Retaliation complaints will not be accepted when:
You are part owner (including family owned) of the business, or a governing member of the business.
Your complaint is about unpaid vacation, holiday pay, severance pay, or reimbursement for
expenses including fuel.
Your complaint is about an employer not providing prescribed rest breaks and/or meals.
You are claiming retaliation against a business while working out of state for a non-Washington
employer.
Your complaint is about protected leave, missing wages or wages owed, prevailing wages, or an
issue of safety and/or health; however...
On separate complaint forms, L&I accepts for the following complaints:
Worker Rights Complaint form
(F700-148-000) for general wages, paid sick leave, or other worker rights
issues that are not protected under the Minimum Wage Act.
Protected Leave Complaint form
(F700-144-000) for family leave, family care, leave for victims of domestic
violence, sexual assault or stalking, spouse military leave, leave for voluntary firefights on the scene.
Prevailing Wage Complaint form
(F700-146-000) for wage complaints related to public works projects.
F700-199-000 Retaliation Complaint Form (Minimum Wage Act & Paid Sick Leave) 04-2018
How to file your retaliation complaint:
Complete and sign the attached form. Use a separate sheet of paper if you need more space to
explain your complaint.
Attach any documents, pay statements, letters, or other information you have that relates to your
complaint, including employer correspondence, if any.
Mail the form to the Department of Labor & Industries, Employment Standards Program, PO Box
44510, Olympia, WA 98504-4510 or bring it to L&I at 7273 Linderson Way SW, Tumwater, WA
98501-5414.
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Important: If you are moving or have a new telephone number let us know right away. Call 360-902-5316 or 1-866-
219-7321. If the Department cannot contact you, it may delay the investigation.
After the Department receives your complaint, the complaint will be assigned to an Industrial
Relations Agent for an investigation. Due to the nature of the investigation, it will be necessary for the
investigator to tell your employer that you filed a complaint.
Timelines and next steps for the investigation:
Timeliness: The Department will evaluate your complaint for timeliness. An employee must file a
complaint within 180 days of the alleged retaliatory action. The Department may, at its discretion,
extend the 180 day period on recognized equitable principles or if extenuating circumstances exist.
Acceptance: In some cases, the Department may seek additional information from you before
assigning your complaint to an agent. The Department will need enough information from you to
determine that there is a prima facie case for retaliation. In other words, the Department needs to be
able to see that you exercised one of your rights under 49.46 RCW and that your employer took an
adverse action against you in connection with exercising your rights. The Department may not accept
your complaint if there is no prima facie case for your complaint based upon the information provided
to us. In some cases, the Department may refer you to another state or federal agency if other types
of discrimination or retaliation are evident.
Investigation: If your complaint is accepted, the Department will investigate your complaint. You will
be contacted by an agent once your complaint has been assigned. The agent assigned to your
complaint will have 90 days to conduct an investigation unless good cause exists to extend the
investigation. You will be notified if the investigation needs to be extended. The agent will gather
evidence from you, your employer, and anyone else who is identified as possessing relevant
evidence. The agent will review the evidence submitted to determine if there is a link between the
exercise of your employee rights and the adverse action taken against you.
During the Investigation: If you reach a mutual agreement with your employer to remedy the
retaliatory action, you may withdraw your complaint. You may also ask to withdraw your complaint at
any time during the investigation by providing a written statement to the agent assigned to your
complaint. The Department will generally grant voluntary requests to withdraw.
After the Investigation: Once the agent has completed their investigation, the Department will either
issue a Notice of Assessment against the employer if we have found sufficient evidence to
substantiate your complaint, or they will issue a Determination of Compliance if they are unable to
substantiate the complaint based upon the available evidence. The employer or employee may
request reconsideration of or appeal the department’s decision.
F700-199-000 Retaliation Complaint Form (Minimum Wage Act & Paid Sick Leave) 04-2018
Retaliation Complaint Form
(Minimum Wage Act & Paid Sick Leave)
Employment Standards Program
Complete this form in full. The employee may
PO Box 44510
Olympia WA 98504-4510
attach additional information on separate pages.
Email:
ESGeneral@Lni.wa.gov
Phone:
360-902-5316
Employee Information
Name (First, Middle Initial, Last)
Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
Email Address
Alternate Contact — We need contact information for someone who will always know how to reach you.
(Do not use your contact information.)
Alternate Contact Name
Alternate Contact Phone Number
Alternate Contact Email Address
Business Information
Business Name
Business Phone Number
Business Address
City
State
Zip Code
Supervisor’s Name
Supervisor’s Phone Number
Supervisor’s Email Address
Human Resources Point of Contact Name
Human Resources Point of Contact Phone Number
Human Resources Point of Contact Email Address
Union Point of Contact Information (if applicable)
Others Knowledge (e.g. other employees with knowledge of retaliation)
What additional information would this person(s) provide to support your claim?
F700-199-000 Retaliation Complaint Form (Minimum Wage Act & Paid Sick Leave) 04-2018
Retaliation Details
INSTRUCTIONS: Please see the instructions sheet to help you answer the following questions. Give a
written statement to each question. An incomplete form will result in delays.
Date(s) of Retaliation
What was the nature of the retaliation or discrimination? (Check all that apply)
Termination
Took action or threatened to take action based on:
Suspension
Immigration status
Demotion
Immigration status of a family member
Change in hours
Other (explain):
Change in pay
Disciplinary action/written warning
Negative performance evaluation
Transfer
Denied/Delayed Payment of:
Wages
Overtime pay
Tips or service charges
Paid sick leave
What Minimum Wage Act right did you exercise? (Check all that apply)
Filed a wage complaint
Requested use, accrual, or other rights related to
paid sick leave
Requested to be paid at least minimum wage
Requested overtime pay
Dates requested/used:
Requested payment of tips or service charges
Testified or intended to testify in a proceeding of
the Department
Briefly describe the circumstances of the retaliation.
Briefly describe why you believe the employer took this action
Have you filed a complaint with any other agency?
No
Yes
If “Yes”, please identify the agency/agencies and date of
filing.
Briefly describe what kind of remedy you are seeking. What do you hope happens as a result of filing this complaint?
Signature
I hereby certify that the information I have provided is true to the best of my knowledge and/or recollection.
Print Name
Title
Signature
Date
F700-199-000 Retaliation Complaint Form (Minimum Wage Act & Paid Sick Leave) 04-2018
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