Fillable Printable Workplace Complaints Form - Australia
Fillable Printable Workplace Complaints Form - Australia
Workplace Complaints Form - Australia
Workplace
Complaint Form
IMPORT
ANT: If your complaint relates to unfair dismissal or termination of your employment, please contact the Fair Work
Infoline IMMEDIA
TELY on 13 13 94. Please note: All questions marked with an asterisk (*) are mandatory.
Please complete this form using black ink.
Fair Work Ombudsman ABN 43884188232 www.fairwork.gov.au
Page 1
Section 1. Complainant details
1.1 Title*
Mr Mrs Ms Miss Dr Other
1.2 Surname/family name*
Given name/s*
1.3 Postal address*
Subur
b/town
1.4
Daytime contact number*
1.5
Email address
1.6 Dat
e of birth
1.7 Do you need an interpreter?*
State
Postcode
Mobile number
D D
M M
Y Y Y Y
Yes No Language
For an interpreter,
contact Translating &
Interpreting Services
(TIS) on 13 14 50
No – Please continue with section 2 Yes
Yes No
1.8 Has someone else completed this form on your behalf?*
1.9 D
o you authorise this person to act on your behalf?
Contact name
Contact number
www.fairwork.gov.auFair Work Ombudsman ABN 43884188232
Section 2. Employer details
Note: You may nd some of these details on the employer’s business letterhead, your pay slips or PAYG payment summary.
2.1 Business name*
2.2 ABN/ACN (Australian Business Number/Australian Company Number)*
2.3 Is/was your employer a small business (under 15 employees)? Yes No
2.4 Full name of the business owner(s) and/or manager Mr Mrs Ms Miss Dr Other
2.5 Workplace contact number* Mobile number
Workplace email address
2.6 Address where you work/worked*
Suburb/town State
Postcode
2.7 Employer’s postal address
Suburb/town State Postcode
Section 3. Details of complaint
The Fair Work Ombudsman can assist with complaints in relation to wages, conditions of employment and workplace rights.
Please contact the Fair Work Infoline on 13 13 94 or visit www.fairwork.gov.au/complaints to conrm that the Fair Work
Ombudsman can assist you.
3.1 Have you called the Fair Work Infoline ?*
No Yes – What is your Reference Number?
3.2 What date did you start working for this employer?
D D
M M
Y Y Y Y
3.3 Are you still working for this employer? Yes – please go to Question 3.5 No – please go to Question 3.4
3.4 What date did you nish working for this employer?
D D
M M
Y Y Y Y
3.5 Were/are you employed as full time part time casual don’t know? (select one only)
3.6 Were/are you employed under an apprenticeship a traineeship neither? (select one only)
3.7 Is/was your employment subject to a working visa?* Yes No Classication
If you are unsure of your visa classication, please call the Department of Immigration & Citizenship on 13 18 81 or visit www.immi.gov.au
3.8 What is/was your job title?
Page 2
www.fairwork.gov.auFair Work Ombudsman ABN 43884188232
3.9 Details of your complaint.*
Using the t ext box below, please provide details of your complaint so that it is clear what all the allegations are. The Fair Work
Ombudsman in managing your complaint may advise your employer that you have made a complaint and the details of
your complaint which may include sending a copy of all or part of your complaint form to your employer (although we will
not forward your address, email or phone number). It is fair that the Fair Work Ombudsman provides this information to your
employer so that your employer can understand what the allegations are and provide a response to your complaint to us.
Unless you elect to tick option 2 in Section 4 below, you give your consent to the Fair Work Ombudsman to provide all or part
of your complaint form to your employer.
Note: General bullying, harassment or workplace conict complaints should be directed to your state or territory
occupational health and safety body.
IMPORTANT: If your complaint relates to unfair dismissal or termination of your employment, please contact the
Fair Work Infoline IMMEDIATELY on 13 13 94.
Page 3
www.fairwork.gov.auFair Work Ombudsman ABN 43884188232
Section 4. Condentiality*
In the course of managing your complaint the Fair Work Ombudsman may want to contact your employer to provide a copy of
your complaint, to request specic information about your employment and/or discuss your allegations. This will result in your
employer being made aware that you have made a complaint about them and your employer being provided with a copy of all or
part of your complaint (although we will not forward your address, email or phone number).
Option 1 – I give permission for the Fair Work Ombudsman to contact my employer for the purpose detailed above.
Option 2 – I DO NOT give permission for the Fair Work Ombudsman to contact my employer for the purpose detailed above.
Note: If you choose Option 2, we will have to keep your complaint condential. In some circumstances we may be unable to
manage your complaint condentially. If this is the case we will advise you.
Contact the Fair Work Infoline on 13 13 94 if you would like to discuss your situation in more detail.
Section 5. Complainant’s declaration and acknowledgement*
I declare that:
• The details I have provided are correct to the best of my knowledge.
• I acknowledge that the Fair Work Ombudsman may disclose or authorise to disclose information likely to assist in the
administration or enforcement of a law of the Commonwealth, a State or a Territory. This includes referring my complaint,
or aspects of my complaint, including any information obtained while investigating my complaint, to other relevant
government agencies, including state/territory agencies, where issues fall within their area(s) of responsibility.
• I acknowledge that the information provided in my complaint form may be used for statistical research, monitoring and
evaluation that may be carried out by the Fair Work Ombudsman, Fair Work Commission, the Department of Education,
Employment and Workplace Relations or contracted commercial researchers, and this will not breach Australian privacy
principles.
Your signature*
Date*
D D
M M
Y Y Y Y
Please ensure you have signed and dated this form before returning it.
Note: You may be asked by the Fair Work Ombudsman to provide supportive documents such as: pay slips, PAYG summaries, time
and wage records, tax declaration forms, employment agreements/contracts, Individual Flexibility Arrangements, correspondence
with your employer, job advertisements, relevant employer policies and forms, medical certicates or other records. These
supportive documents may also be released to your employer/former employer if the Fair Work Ombudsman believes this may
assist in resolving your complaint.
Please post this completed form to:
Fair Work Ombudsman
Complaints Assessment Team
GPO Box 2567
Adelaide SA 5001
The Fair Work Ombudsman manages personal information in accordance with the Privacy Act 1988. Information in your complaint form will be used for the purpose
of determining whether Commonwealth workplace laws are being adhered to.
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Fair Work Ombudsman ABN 43884188232 www.fairwork.gov.auPage 5
April 2013 FWOCF3
www.fairwork.gov.au
Fair Work Infoline 13 13 94
Investigating your complaint – what may happen next?
The Fair Work Ombudsman will consider the information provided in your complaint and decide our response. The Fair Work
Ombudsman will make a decision about the best course of action to assist in resolving your complaint. The Fair Work Ombudsman
might decide:
• thatthematterisoutsideofourjurisdictionandreferyousomewhereelse
• thattherehasn’tbeenabreachofCommonwealthworkplacelaws
• thatvoluntaryresolutionprocessessuchasmediationarethebestwaytoresolvetheissues
• toconductaninvestigation
• toconductanaudit.
For more information on what may occur once the Fair Work Ombudsman has received your complaint, please go to
www.fairwork.gov.au
Please note that in all cases the Fair Work Ombudsman is neutral and represents neither an employee nor an employer. In some
instances the Fair Work Ombudsman may not be able to assist with your complaint.
