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2. Complainant*
4. Job Title*
5. Department*
7. Email Address*
8. Supervisor's Name*
10. Home Address:
12. Work # ( )
13. Home # ( )
14. Cell # ( )
16. ISSUE(S)

    1. Denial of Selection
    2. Termination
    3. Constructive Discharge
    4. Differential Treatment
    5. Denial of Reasonable Accommodation

    1. Denial of Training
    2. Lay-off
    3. Disciplinary Action
    4. Sexual Harassment

    1. Denial of Promotion
    2. Denial of Leave
    3. Harrassment
    4. Other (please specify)
18. ALLEGATION(S) BASED ON:

    1. Age (40 and over)
    2. Sex/Gender
    3. Pregnancy
    4. Request for Pregnancy Disability Leave
    5. Retaliation for Protesting Discrimination
    6. Request for Leave for an Employee's Own Serious Health Condition

    1. Marital Status
    2. Religion
    3. Retaliation for Reporting Patient Abuse in Tax Supported Hospitals
    4. Political Beliefs
    5. National Origin/Ancestry (including language use restrictions)

    1. Race/Color
    2. Request for Family Care Leave
    3. Disability (mental and physical, including HIV and AIDS)
    4. Genetic Characteristics and information
    5. Medical Condition (Cancer)

    1. Union Activity
    2. Sexual Orientation
    3. Military or Veteran Status
    4. Gender Identity/Gender Expression
    5. Other (Please specify)
20. Names and Titles*
    Name and title(s) of person(s) causing discrimination and/or harrassment:
22. 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:
24. 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.
26. Attach document
28. Date
29. Name of Complainant
31. Remedy
    What remedy are you seeking?
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

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