Sexual Harassment Or Discrimination Complaint Form
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STATE OF NEVADA
Sexual Harassment or Discrimination Complaint Form
Sexual harassment and discrimination based on race, color, national origin, religion, sex,
age, disability, pregnancy, sexual orientation, gender identity or genetic information in
any term, condition or privilege of employment are violations of State and federal law.
(This form may be completed by the complainant or person receiving the complaint)
Date of Complaint:
For more efficient processing, submit this complaint online in the NEATS system.
Please answer the questions completely and use as many additional sheets as necessary.
If you do not use the NEATS online system, then submit this completed form to your agency
coordinator or the Division of Human Resource Management’s Sexual
Harassment/Discrimination Unit at 100 North Stewart Street, Suite 200, Carson City, Nevada
89701-4204, or fax to (775) 684-0124.
Complainant Name:
Title:
Immediate Supervisor:
Department:
Division:
Section/Unit:
Work Location:
Work Phone:
Home Address:
Home Phone:
1. Type of Complaint:
Check the type of discrimination or harassment that relates to this complaint:
Sexual Harassment
Sex Discrimination
Racial Discrimination
Age Discrimination
Religious Discrimination
National Origin Discrimination
Disability Discrimination
Pregnancy Discrimination
Color Discrimination
Sexual Orientation
Gender Identity
Genetic Information
*Hostile Work Environment
*Hostile Work Environment and Retaliation must be based
*Retaliation
on one of the protected groups listed above. Check if appropriate.
If you make a complaint of sexual harassment/ discrimination it will be investigated. Please initial
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