Wioa Grievance Information Form - Georgia Department Of Economic Development Workforce Division

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Georgia Department of Economic Development
Workforce Division
WIOA Grievance Information Form
INSTRUCTIONS: Please fill out Questions 1-5 for a general complaint. If you feel you have been discriminated
against, please complete Questions 6-11. This form should be completed and submitted within one hundred and
eighty (180) days of the date of the alleged discriminatory act (29 C.F.R. §38.69(c)). Once you have completed the
appropriate questions, please sign and date at the end of this form. If you require assistance in completing this
form, please contact the Georgia Department of Economic Development, Workforce Division (WFD), and request
the Compliance Team.
For general complaints and pursuant to Section 181 of the Workforce Innovation and Opportunity Act, the State shall
provide the complainant with an opportunity for a hearing within sixty (60) days of the complaint’s filing, if expressly
requested in writing by the complainant. In the event a hearing is not requested, WFD shall issue a decision as
to whether provisions of the Workforce Innovation and Opportunity Act were violated within sixty (60) days of
the complaint’s filing. In the event the complainant is dissatisfied with the State’s decision or the State fails to
issue a decision within sixty (60) days of the complaint’s filing, he or she may appeal the State’s decision to, or notify
if the State failed to respond within sixty (60) days, the United States Department of Labor Secretary. If such an
appeal is made, the Secretary shall issue a final determination within one hundred and twenty (120) days of the
receipt of the appeal.
Georgia Department of Economic Development, Workforce Division
ATTN: Deputy Counsel David Dietrichs
75 Fifth Street, NW, Suite 845, Atlanta, GA 30308
Phone (404) 962-4005 Fax: (404) 876-1181
Submissions should be sent to:
1. Complainant Information:
First Name
MI
Last Name
Address
City
State
Zip
Home Telephone (
)
-
Work Telephone (
)
-
 Yes
 No
Email Address
Are you a GDEcD Employee?
2. Respondent (Agency, Employee, or Employer you are making the complaint against):
Name
Telephone (
)
-
Address
City
State
Zip
3. What is the most convenient time for us to contact you about this complaint?
4. Briefly describe, as clearly as possible, your complaint. Attach additional sheets if necessary. Also, attach any
written materials pertaining to your complaint.
a.
Please explain the basis of the complaint.
b.
Who was involved? Include witnesses, fellow employees, supervisors, or other. Provide names,
addresses, and telephone numbers if known.
c.
Please list the location and date.
 Yes
 No
 N/A
5. Were you offered employment services? (if applicable)
This is all that is required for a general complaint, please sign and date at the end of this form.

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