Eeo Complaint Form

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EEO COMPLAINT FORM
Please print the following information:
Name:
SS# (last 4 digits):
Title:
Unit/Dept.:
Supervisor’s Name:
Work Address:
Office Telephone
(
)_______________________
What is the basis of the alleged EEO Violation? (Check only those civil rights categories that apply to your complaint)
Age:
Partnership Status:
Alienage /Citizenship:
Predisposing Genetic Characteristic:
Arrest/Conviction Record
Race:
Color:
Religion:
Creed:
Sexual Harassment:
Disability:
Sexual Orientation:
Gender:
Military Status:
Marital Status:
National Origin:
Status as Victim of Domestic Violence, Sex Offenses or Stalking:
Retaliation for opposing discrimination, filing an EEO complaint or assisting in an EEO investigation:
What terms and conditions of your employment do you believe have been affected by the EEO violation?
Recruitment
Testing
Hiring
Work Assignments
Transfer
Salary
Benefits
Leave
Performance Evaluation
Promotion
Demotion
Training Opportunities
Discipline
Working Conditions
Termination
Other
EEO-1 (08/08)

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