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Discrimination Online Complaint Form
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Complainant
*
Job Title
*
Department
*
Email Address
*
Supervisor's Name
*
Home Address:
Work # ( )
Home # ( )
Cell # ( )
ISSUE(S)
Denial of Selection
Termination
Constructive Discharge
Differential Treatment
Denial of Reasonable Accommodation
Denial of Training
Lay-off
Disciplinary Action
Sexual Harassment
Denial of Promotion
Denial of Leave
Harrassment
Other (please specify)
ALLEGATION(S) BASED ON:
Age (40 and over)
Sex/Gender
Pregnancy
Request for Pregnancy Disability Leave
Retaliation for Protesting Discrimination
Request for Leave for an Employee's Own Serious Health Condition
Marital Status
Religion
Retaliation for Reporting Patient Abuse in Tax Supported Hospitals
Political Beliefs
National Origin/Ancestry (including language use restrictions)
Race/Color
Request for Family Care Leave
Disability (mental and physical, including HIV and AIDS)
Genetic Characteristics and information
Medical Condition (Cancer)
Union Activity
Sexual Orientation
Military or Veteran Status
Gender Identity/Gender Expression
Other (Please specify)
Names and Titles
*
Name and title(s) of person(s) causing discrimination and/or harrassment:
Witness(es)
*
Name(s), title(s), and contact information of witness(es) or person(s) who may have relevant information or evidence helpful to the investigation and resolution of the complaint:
Circumstances
*
Describe in detail the circumstances surrounding your allegations of discrimination and/or harassment. Please include date(s), time(s) and locations where the act(s) occcurred and use a separate sheet of paper if more room is needed and attach to this document.
Attach document
Date
Name of Complainant
Remedy
What remedy are you seeking?
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