Statement of Alleged Violation of the Connecticut Family and Medical Leave Act

If you need to report a possible violation of the Connecticut Family and Medical Leave Act with our Wage and Workplace Standards Division, you may now access a copy of the Statement of Alleged Violation of the Connecticut Family and Medical Leave Act Form (WORD, 85KB) through our Web site. This form was previously available only through the mail or by visiting your local Connecticut Works Career Center.

Please note that because the form requires your signature, it is not a data entry form. To use the form, you must print it out. Once you have produced a paper copy of the form, please print or type the information requested, sign the form, and return it to the address provided at the top of the form.

If you need assistance in completing this form, please contact the Wage and Workplace Standards Division at (860) 263-6790 or your local Connecticut Works Career Center.