Reprisal Complaint

Reprisal is any action or threat of action by an employer or union that negatively affects a worker’s employment circumstances.
Workers are protected from reprisal when performing protected activities listed under section 53 of the Workers’ Safety and Compensation Act.
Workers have two choices for reprisal complaints:
1. Collective Agreement: A worker can choose to follow their workplace’s dispute resolution process, as set out in their collective agreement, if there is one. (Timelines and processes applicable would be set out in the applicable collective agreement, please refer to your collective agreement and make appropriate inquiries); or
2. Complaint to the board: A worker can complete the board’s complaint form and send it directly to us.
Reprisal Complaints filed with the board must be submitted within 21 days of the date of the alleged reprisal.
PLEASE NOTE: A worker may choose only one way to make a complaint about the reprisal. If a worker chooses or has already chosen to use their collective agreement process then a reprisal complaint cannot be filed with the board.

If you have a concern about a health and safety matter at a workplace, please contact the Workplace Health and Safety Branch at 867-667-5450 or toll-free at 1-800-661-0443.

Worker Contact Information

First Name

Middle Name

Last Name

Email

Primary Phone

Secondary Phone

Street Number

Street Address

PO Box

City

Province/Territory

Country

Postal Code

Job Title

What was the position you were working in during the period of the reprisal you are reporting?

Date Hired

Tell us the month and year you started with the employer involved in the reported reprisal.

What is your current employment status with the employer

Quit Fired Laid off Still work there Other

Tell us what the status of your employment with the employer involved in the reported reprisal.

What is the last day you worked

Tell us the day you last worked for the employer involved in the reported reprisal. If you are still working for this employer please enter todays date.

Employer Contact Information

Company Name

Legal Name

Primary Phone Number

Street Number

Street Address

PO Box

City

Province/Territory

Country

Postal Code

Nature of Work

What is the type of work that this business generally does?

Supervisor or Manager's Name

What is the name of the person who managed or supervised you at the time of the reprisal you are reporting?

Workplace Address

“Workplace” means a building, site, project site, workshop, structure, vehicle or mobile equipment, or any other location where one or more workers perform or have performed work.

Street Address

Provide the street address of where you performed work. If there is no street address, provide the best description.

City or Town

What is the community of the workplace, or the community nearest to the workplace?

Postal Code

What is the postal code of the workplace?

Description of Events

Check each protected activities you took part in:

Select all that apply.

Describe your involvement in the protected activity(s) you selected above

Describe the disciplinary action that was taken against you

Why do you think the disciplinary action is related to your involvement in the protected activity?

Describe any steps you took to resolve this matter with the employer

Signature, consent and declaration

This information is being collected for the purposes of administering and enforcing the Workers’ Safety and Compensation Act and is collected under the authority of that Act and the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the Privacy Officer at WSCB at the above listed address or at (867)667-5645 or 1-800-661-0443

I acknowledge that electronic communication has inherent security risks, as do all forms of communication. Notwithstanding the inherent risks of electronic communication, I consent to the use of electronic methods to transmit and receive information, including confidential and personal information between the board and myself. This consent will remain in effect until written notice to revoke this authorization has been received by the board.

By signing and dating this form, I agree that I have read this Form and certify that the statements contained within are true, complete, and accurate to the best of my knowledge. I understand that:

4.1 Providing false or misleading information is against the law and is an offence under the Act. The consequences for giving false or misleading information are administrative penalties or prosecution.

4.2 A copy of this complaint will be fully disclosed to the employer named in section 2 above.

4.3 I have not filed a complaint through my collective agreement about the reprisal reported on this form.

4.4 Any changes to my Worker Information during the investigation will be emailed to the Workplace Health and Safety Branch at: [email protected]

<b>By checking this box I declare that the information provided is true and correct. </b>

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