Fill and Sign the Discrimination Form

COMPLAINT FORM 1. ________________________________________________________________Name in full ( complainant, please print) ________________________________________________________________ Street City State Zip Code Home Phone No. ________________________________________________________________ D epartment Position/Title Work Phone No. 2. Select your classification: Executive Staff Supervisor/Manager Support Staff Other _________ 3. Nature of alleged discrimination: Race Sex Religion Age Retaliation Handicap/Disability Sexual Harassment National Origin Other ______________ 4. The alleged discrimination occurred in connection with (check all that apply) : Interview Retaliation Hiring Selection Termination Other ___________ 5. Name(s), Title(s), Department(s) and Telephone Number(s) of Person(s) who you believe discriminated against you: ________________________________________________________________ Name Position/Title ________________________________________________________________ Department Telephone Number ________________________________________________________________ Name Position/Title ________________________________________________________________ Department Telephone Number (Use additional sheets if necessary) 6.Date on which incident(s) occurred: __________________________ 7. Location of incident(s):______________________________________ 8. Name(s) of witness(es): ______________________________________ 9. Please supply any supporting evidence to document the basis for the alleged discrimination you are claiming, as indicated in your response to numbers 5 and 6 of this form. I have attached supporting documents: Yes No If yes, describe attachments: ________________________________________________________________ ________________________________________________________________________________________________________________________________ 10. Describe the alleged discrimination you and/or others were subject to: ________________________________________________________________ ________________________________________________________________________________________________________________________________ 11. Qualifications for position/placement sought; or, why dismissal was not justified: ________________________________________________________________ ________________________________________________________________________________________________________________________________ 12. What action(s) do you feel are necessary to remedy the alleged discrimination? ________________________________________________________________ ________________________________________________________________________________________________________________________________ 13. List those persons with whom you have discussed the incident(s): ________________________________________________________________ ________________________________________________________________________________________________________________________________ 14.Have you filed a complaint outside of the company? Yes No If yes, please list entity or attorney handling your complaint. Include all contact information: ________________________________________________________________ Name Address Phone Number 15. Have you tried to resolve this issue through your supervisor(s) and/or the company’s grievance procedure? Yes No If yes, please explain: ________________________________________________________________ ________________________________________________________________________________________________________________________________ I understand the following: 1. I affirm that I have read the above information and that it is true and correct to the best of my knowledge. 2. I understand that at anytime I have the right to file a complaint with an outside state and/or federal agency, or file suit in a court of law. _________________________________ _________________________________ Signature of Complainant Human Resources Representative Date: _______ Date: _______ Complainant is not required to sign this form. Note to Human Resources Representative: If complainant does not want to sign this form, ask him/her to verify the information and correct any of the information that is not correct.