For Office Use Only: DC#
FIFTH JUDICIAL DISTRICT
DEPARTMENT OF CORRECTIONAL SERVICES
EQUAL EMPLOYMENT OPPORTUNITY/AFFIRMATIVE ACTION OFFICE
Discrimination Complaint Form
Complaints should be filed promptly but no later than one hundred eighty (180) days from the date of the alleged discriminatory act(s).
Any employee, applicant of the Department who has reason to believe that he/she has been the victim of discrimination may file a complaint by submitting a Discrimination Complaint Form.
NAME_______________________________________________________________________________________________
Last First Middle Name or Initial
ADDRESS_____________________________________________________________________________________________
City State Zip Code County
TELEPHONE (____)_________________________(_____)____________________________________________________
Area Code Home # Area Code Business#
Date(s) of alleged discriminatory act(s) (1) ____/_____/_____ (2) ____/______/____
Mo Day Yr Mo Day Yr
Basis of alleged discriminatory act(s) (check appropriate box or boxes).
Race Age Mental Disability
Creed Sex Physical Disability
Color Religion Political Affiliation
Gender Identity National Origin Sexual Orientation
Who committed the alleged discriminatory act(s)?
Name of Person___________________________________________________
Title of Person____________________________________________________
Name and location office (if applicable)
_________________________________________________________________
_________________________________________________________________
Area in which the alleged discrimination act(s) occurred. (Check appropriate box or boxes).
Hiring Promotion Tran Transfer
Wages Assignment(s) Separation/Termination
Lay Off Demotion Reta Affiliation
Other (please specify) ___________________________________________________________________________
Description of alleged discriminatory act(s). (Please describe in detail the circumstances surrounding the alleged discrimination, including any steps you have taken to deal with the issue. Attach additional sheet(s) if more space if needed.)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
What corrective actions are you seeking? _____________________________________________________________
______________________________________________________________________________________________
Have you filed this complaint with any other Local, State or Federal Government Agency? ____Yes ____No
a) If yes, which agency(ies)?______________________________________________________________________
b) When did you file (1) ____/_____/_____ (2) ____/_____/_____
Mo Day Yr Mo Day Yr
What is the status of your complaint?____________________________________________________________
Attach any written materials, data or other documents which you think are relevant to your complaint.
I certify that the information given above is true and correct to the best of my knowledge or belief.
Complainant’s Signature______________________________________________________ Date _____________________
Received by (Name)__________________________________________________________ Date _____________________
Title ________________________________________________________________________________________________
Approved by:
11 STATUTS TYPE SÀRL OFFICE FÉDÉRAL
2 UNITED NATIONS OFFICE AT VIENNA OFFICE
3 FOR OFFICE USE FEE RECEIVED £
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