Eeo Complaint Form Page 3
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4Did you use more pages? Yes ___ No ___
Were there any witnesses to the alleged EEO violation? Yes ___ No ___
Please give names, titles and divisions/station of any witnesses to the EEO violation. (Include
names, titles
[A witness is someone who observed or heard something concerning the
and work locations of each person)
allegations or has other relevant information concerning the allegations]
Did you report this to anyone: If so, please list the names, titles and work locations of each person:
Have you filed a complaint about the alleged EEO violation with any of the following external agencies?
Yes ___ No ___ If Yes, please state the date and number of the complaint.
Date
Complaint Number
New York City Commission
on Human Rights
________________
__________________
New York State Division
on Human Rights
________________
__________________
United States Equal Employment
Opportunity Commission
________________
__________________
United States Department
of Labor
________________
___________________
New York City
Department of Investigation
_______________
_________________
AFFIRMATION
I affirm that I have read the above charge and that it is true to the best of my knowledge, information
and belief.
___________________________________
_________________
Signature
Date
EEO -1 (08/08)
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