Formal Complaint Form Employment Standards Division Introduction

Formal Complaint Form
Employment Standards Division
Introduction
If an employee believes The Saskatchewan Employment Act is not being followed she or he can file a
formal complaint with the Employment Standards Division. The complaint could involve monetary
issues such as not being paid overtime or vacation pay or not being paid correctly. It could also involve
non-monetary issues such as not getting a work schedule or a pay stub or not being paid on time. The
Investigative Unit of the Employment Standards Division will investigate the complaint.
An employee has a year following the last day that wages were payable to register his or her complaint
with the Employment Standards Division.
How to file a complaint
Employees may file a written complaint by mailing or faxing the Division a completed Formal Complaint
Form or a letter if a form is not available. Employees can also make an appointment to meet with an
intake staff member or a Employment Standards Officer at any one of our eight District Office locations
throughout the province. (See the list of locations at the end of this form).
An Employment Standards Officer will investigate the complaint
A formal complaint means the employee is requesting that an Employment Standards Officer conduct
an investigation into a potential violation of The Saskatchewan Employment Act or regulations.
Employment Standards Officers are authorized to obtain and review evidence, resolve claims and, where
necessary, enforce the provisions of the Act or regulations.
Evidence should be provided
Evidence supporting your claim (i.e. pay stubs, records of hours worked) should be provided. This will
help streamline the process. Failure to provide evidence may result in the investigation taking longer to
complete.
When the Division receives the complaint
Division staff will review the complaint and may call the employee for more information. They will also
contact the employer and may inspect the employer’s payroll records, talk with other employees, and
gather other evidence.
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The Officer’s investigation is conducted to ensure compliance with the legislation. The Officer is not the
complainant’s advocate. The investigative process will take time and the complaint will not likely be
resolved immediately.
No fees or charges
There is no fee or charge for making a complaint or talking to someone from the Employment Standards
Division.
Tips for Completing the Formal Complaint Form
Complete the Formal Complaint Form in full with as much information as possible and ensure it
is signed. Any supporting documentation should be attached to the form before returning it to the
Employment Standards Division.
1. INFORMATION ABOUT YOU: Provide your name, address and phone number and the name and
phone number for an alternate contact person. If you move while the investigation is ongoing, please
notify the investigating Officer.
2. INFORMATION ABOUT THE EMPLOYER YOU ARE FILING THE COMPLAINT AGAINST: Provide as
much information about the employer as possible. Include the employer’s name, address and phone
number along with the supervisor’s or manager’s name and contact information.
3. YOUR WORK HISTORY WITH THIS EMPLOYER: Provide as much information as possible about your
work time with this employer including your current employment status, job title, hours worked, rate
of pay and pay period.
4. NATURE AND DETAILS OF YOUR COMPLAINT: Use section 4 and 5 to explain what your complaint
is about. Attach any additional information you think might help with the investigation of the
complaint.
5. EMPLOYEE DECLARATION: The investigation cannot proceed without your signature. Please read
the declaration carefully to ensure that you understand what you are agreeing to. Sign and date the
application. Be sure to attach supporting documentation.
Mail or fax the completed form and documentation to the:
• Employment Standards Division District Office located nearest to where you worked. (See the list at
the end of this form.) Please note that your claim may need to be transferred to another District for
investigation.
• You will receive a letter or phone call acknowledging that your claim and documentation have been
received.
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Formal Complaint Form
1. INFORMATION ABOUT YOU
Last Name
 Mr.
 Miss
 Mrs.
First or Given Name
Date of Birth
 Ms.
day/month/year
Mailing Address (street name and # and/or Box #)
City/Town and Province Postal Code
Social Insurance Number
Email (optional)
Telephone #
Cell #
Work #
( )
Alternate Contact
Person Name
( )
( )
Mailing Address (street name and # and/or Box #)
Fax #
( )
Telephone #
(
)
2. INFORMATION ABOUT THE EMPLOYER YOU ARE FILING A COMPLAINT AGAINST
Name of Employer, Company, or Business
General Contractor and Project/Site Location
Street Address and/or Employers’ Mailing Address
City/Town and Province
Postal Code
Telephone #
Fax #
( )
Name of Supervisor
(
Type of Business
)
Telephone #
(
)
Is employer still in business?  Yes  No
Head Office Address: (If different from Employers’ Address above)
3. YOUR WORK HISTORY WITH THIS EMPLOYER
 Still Employed
 Fired
 Quit
Job Title
First Day Worked for this Employer
day/month/year
Salary/Hourly Rate of Pay
$
 Laid-off
Last Day worked for this Employer
day/month/year
If paid by the mile or by a percentage of the load, commission,
etc. please describe:
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Number of Days Worked per Week
Number of Hours Worked per Week
Other
Type of Pay Period:  Daily
 Every Two Weeks
 Monthly
 Weekly
Where does your Employer bank?
 Twice a Month
 Other: _____________________
Do you have relevant
records to support your
claim?
If YES, list records and ATTACH photocopies to this form
 Pay Stub
 Record of Employment (ROE)
 Letter(s)
 Timesheet(s)/Calendar
 Other: __________
 Yes
 No
4. NATURE OF YOUR COMPLAINT
Check all that apply:
Date
Date
Estimated Amount Owing
From:
To:
$
 Regular Wages
From:
To:
$
 Overtime
From:
To:
$
 Annual Vacation Pay
Specify Dates
 Public Holiday Pay
Specify:
 Pay instead of Notice
 Maternity/Parental/Adoption Specify:
Specify:
 Illness/Injury
Specify:
 Deductions from Wages
Estimated Total
$
 Other(please specify)
5. DETAILS OF YOUR COMPLAINT (Attach any additional information to the form)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
If covered by a Union Contract, what is the name
of the Union
Union Representative
Was this Complaint made to another Government Agency?  Yes Telephone #
(
)
 No
If yes, explain: ____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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6. EMPLOYEE DECLARATION
I, ______________________________________________________________________________________
(Please print your name)
• certify the information submitted is true and complete to the best of my knowledge and I
understand that any person who makes a false or misleading statement in this complaint form
with the intent to deceive, is guilty of an offence under The Saskatchewan Employment Act.
• am not proceeding with any other action to secure payment for my claim.
• will inform the Employment Standards Division of any change to my address, phone number or
email.
• will inform the Employment Standards Division of any payment or settlement I receive from the
employer or any other source that applies to my claim.
• understand the Employment Standards Division may provide a complete copy of this complaint
form to the employer about whom I am complaining. Any other information I provide, now and
during the course of the investigation, may be shared with this employer.
• consent to the transfer of my complaint to another Canadian employment standards office if
necessary.
• consent to the Employment Standards Division making wage collection efforts on my behalf,
which may include obtaining and sharing information and representing my claim with trustees or
receivers, including in situations involving the Federal Wage Earner Protection Program.
• consent to the collection of personal information as defined by The Freedom Of Information and
Protection of Privacy Act for use and disclosure in matters pertaining to the investigation and
resolution of my claim.
______________________________________________________________________________
(Employee’s Signature)
Dated at: _____________________________ this _______ day of____________________, 201____.
For information about making an anonymous complaint:
• call CRU toll free at 1.800.667.1783 or 306.787.2435 (Regina);
• call, write or visit any one of the eight district offices throughout the province; or
• view the website at saskatchewan.ca/work
FOR OFFICE USE ONLY
Date received:
Received by:
 Mail
 Dropped off
 Fax
 Interview
____________________________________________ __________________________________
(Employment Standards Division Representative Signature)
(Referred to)
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Please mail or FAX this completed form to
Compliance and Review Unit
Employment Standards Division
300 - 1870 Albert St.
REGINA SK S4P 4W1
Call toll free: 1.800.667.1783; in Regina: 306.787.2438
Visit our website: saskatchewan.ca/work
Employment Standards Division District Offices
Please direct all correspondence, including the city and address, to the Employment Standards District
Office closest to you.
Estevan North Battleford
Employment Standards Division Employment Standards Division
P.O Box 5000-160 E101- 1192 102nd St.
rd
123 - 1302 3 St. NORTH BATTLEFORD SK S9A 1E9
ESTEVAN SK S4A 2V6 Tel: 306.446.7491
Tel: 306.637.4572 Fax: 306.446.8729
Fax: 306.637.4574
Moose Jaw Swift Current
Employment Standards Division Employment Standards Division
222 - 110 Ominica St. W. 2nd Floor, 350 Cheadle St. W.
MOOSE JAW SK S6H 6V2 SWIFT CURRENT SK S9H 4G3
Tel: 306.694.3737 Tel: 306.778.8246
Fax: 306.694.3815 Fax: 306.778.8682
Saskatoon Regina
Employment Standards Division Employment Standards Division
8th Floor, 122 3rd Ave. N. 300 - 1870 Albert St.
SASKATOON SK S7K 2H6 REGINA SK S4P 4W1
Tel: 306.933.5042 Tel: 306.787.2438
Fax: 306.933.5444 Fax: 306.798.8001
Yorkton Prince Albert
Employment Standards Division Employment Standards Division
st
1 Floor, 72 Smith St. E. P.O. Box 3003
YORKTON SK S3N 2Y4 3rd Floor, 800 Central Ave.
Tel: 306.786.1390 PRINCE ALBERT SK S6V 6G1
Fax: 306.786.1541
Tel: 306.953.2715
Fax: 306.953.2673
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