Form Il452Pr01 – Fill Out and Use This PDF

PERSONNEL RECORDS REVIEW ACT	Complaint Form
Illinois Department of Labor	PLEASE PRINT OR TYPE ALL INFORMATION
160 N. LaSalle Street, Ste. C-1300

CLAIMANT INFORMATION:

Your Name

Address

City

State

Zip

Home Telephone

E-MAIL

Dates of Employment: From

to:

(Mo/Day/Year)

(Mo/Day/Year)

Have you been laid off subject to a recall?

Yes

No

Recall date:

EMPLOYER INFORMATION:

Business Name

Address

City							State		Zip
Contact Name					Phone Number
Total Number of Employees:

GENERAL INFORMATION:

1.Date of last review of records

2.Which specific item(s) do you wish to review?

3.Has your employer refused you access to your records? Yes No Reason stated:

4.Has your employer without notice or authorization disclosed your disciplinary records? Yes No If yes, which company representative disclosed your disciplinary records? How? When? To whom?

Page 1 of 2

FORM IL452PR01

5.Is there a representative (e.g. attorney or union) whom you are authorizing to obtain a copy of your records? Yes No If yes, please provide his or her name and address:

6. Is there any information in the records with which the employee disagrees and for which the employee is seeking a correction, removal or

attachment or a rebuttal by employee?

Yes

No

If yes, please list the document(s) with type/name and date(s):

7.Has your employer gathered or kept a record of your associations, political activities, publications, communications or non-related activities without your written authorization? Yes No

If yes, give specifics:

8. Other complaints under this Act:

Please read carefully before signing

I am requesting the assistance of the Illinois Department of Labor in the handling of this complaint. I realize it is necessary for the Department to disclose the existence and nature of this complaint and to reveal my name to my (former) employer. I hereby certify that all the information provided in this form and complaint is true and correct to the best of my knowledge and belief.

Signature

Date

(must have original signature)

Page 2 of 2

FORM IL452PR01