Wioa Grievance Information Form - Georgia Department Of Economic Development Workforce Division Page 2
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2Please complete this section if you suspect you have been or are being discriminated against.
Pursuant to 29 C.F.R. §38.35, a discriminatory complaint must be filed within one hundred and eighty (180)
days of the alleged discriminatory act. Per 29 C.F.R. §38.72 WFD will provide a “Written Notice of Final Action”
within 90 days of the date on which the complaint was filed.
If the complainant is dissatisfied with WFD’s decision, or if WFD fails to issue a notice of Final Action within the
90-day period, the complainant, or his/her representative, may file a complaint with the Director of the United
States Department of Labor’s Civil Rights Center within thirty (30) days of receiving the Written Notice of Final
Action (§38.72 and §38.76). To clarify, the complainant must file with the Director within one hundred and
twenty (120) days of the date on which the complaint was filed with the recipient (§38.76).
Yes
No
6. Do you feel you have been discriminated against?
7. On what date did the alleged discriminatory action occur?
8. Check all grounds of discrimination that apply and specify the characteristic.
Race
Citizenship
Religion
Sexual Harassment
Sex
Age
Political Affiliation or belief
Pregnancy
Reprisal/Retaliation
Childbirth, and related
Color
medical conditions
National Origin
Sex stereotyping
Limited English Proficiency
Transgender status
WIOA Beneficiary Status_________________
Gender identity
Disability
Other
9. How were you treated differently?
Yes
No
10. Do you have an attorney or other representative for this complaint?
If yes, please provide the following:
Name
Telephone (
)
-
Address
City
State
Zip
11. If you have filed a case or complaint with any other government agency or non-federal entity, please list
below:
Agency
Date filed
Case or Docket No.
Date of Trial or Hearing
Location of Agency or Court
Name of Investigator
Status of Case
Comments
I certify that the information furnished above is true and accurately stated to the best of my knowledge. I
authorize the disclosure of this information to enforcement agencies for the proper investigation of my
complaint. I understand that my identity will be kept confidential to the maximum extent possible consistent
with applicable law and a fair determination of my complaint.
Complainant Signature
Date
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