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 JULY 15 2015 THE HONORABLE NATHAN DEAL OFFICE
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RESEARCH REPORT  CORRECTIONAL OFFICER RECRUITS AND THE
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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).

IMPORTANT: This form is covered by the Privacy Act of 1974


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#


  1. Date(s) of alleged discriminatory act(s) (1) ____/_____/_____ (2) ____/______/____

Mo Day Yr Mo Day Yr


  1. Basis of alleged discriminatory act(s) (check appropriate box or boxes).

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Race Age Mental Disability


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Creed Sex Physical Disability


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FOR OFFICE USE ONLY DC     Color Religion Political Affiliation


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FOR OFFICE USE ONLY DC     FOR OFFICE USE ONLY DC     Gender Identity National Origin Sexual Orientation


  1. Who committed the alleged discriminatory act(s)?


    1. Name of Person___________________________________________________


    1. Title of Person____________________________________________________

    2. Name and location office (if applicable)

_________________________________________________________________

_________________________________________________________________


  1. Area in which the alleged discrimination act(s) occurred. (Check appropriate box or boxes).

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Hiring Promotion Tran Transfer


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Wages Assignment(s) Separation/Termination


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Lay Off Demotion Reta Affiliation


Other (please specify) ___________________________________________________________________________


  1. 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.)

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


  1. What corrective actions are you seeking? _____________________________________________________________

______________________________________________________________________________________________


  1. 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


    1. What is the status of your complaint?____________________________________________________________


  1. 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 ________________________________________________________________________________________________


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