Report Covid-19 Vaccine Mandate by Your Employer

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Covid-19 Web Submission Form

Use this form to submit a complaint of an adverse action caused by a COVID-19 Vaccine Mandate. The incident must have happened on or after February 6, 2024. The law requires TWC to implement rules and regulations before an issue can be investigated. TWC will investigate your complaint according to those rules.

SUBMITTER INFO

Name

Phone

10-digit phone number (digits only, no spaces, dashes, or parentheses)

Submitter Address

Must include: Street, City, State, Zip Code, Country. Only letters, numbers, spaces, and basic punctuation allowed.

Counties

Date of Birth

Employment Status

Employment Start Date

EMPLOYER INFO

Company Name

Company Address

Company Phone Number

Name of Human Resources manager OR Company Owner

Name of Person this Complaint is About (Person Who Took the Adverse Action)

Email of the Person Who Took the Adverse Action

DETAILS

Did the employer try to correct the issue?

Incident Date

Is This Your First Time Reporting an Incident with This Employer?

Explanation of Complaint / Nature of Adverse Action

Attach Supporting Evidence (PDF, images, docs only)

Upload supporting documents or images (max 20 MB). Allowed: PDF, Word, text, JPG/PNG/GIF/BMP.
Unlimited number of files can be uploaded to this field.
20 MB limit.
Allowed types: pdf, doc, docx, txt, rtf, jpg, jpeg, png, gif, bmp.

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