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. saskatchewan.ca | 1.800.667.1783 | Page 1 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. saskatchewan.ca | 1.800.667.1783 | Page 2 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: saskatchewan.ca | 1.800.667.1783 | Page 3 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: ____________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ saskatchewan.ca | 1.800.667.1783 | Page 4 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) saskatchewan.ca | 1.800.667.1783 | Page 5 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 saskatchewan.ca | 1.800.667.1783 | Page 6