Sexual Harassment Or Discrimination Complaint Form (Page 4 of 4) in pdf

Sexual Harassment Or Discrimination Complaint Form Page 4

NOTE:

Please attach any supporting documentation to this form.

I,________________________________ certify this statement is true and factual.

(complainant name)

__________________________________________

______________________

Complainant Signature

Date

* * * * * * * * * * * * * * * * * * * * * * * * * * *

Note: Complaints of sexual harassment and discrimination may also be filed with:

Nevada Equal Rights Commission

1675 East Prater Way, Suite 103

555 E. Washington Ave., Suite 4000

Sparks, NV 89434

Las Vegas, NV 89101

(775) 823-6690

(702) 486-7161

Equal Employment Opportunity Commission

(800) 669-4000

Northern Nevada Counties

Southern Nevada Counties

350 The Embarcadero, Suite 500

333 Las Vegas Blvd., Suite 8112

San Francisco, CA 94105-1260

Las Vegas, NV 89101

(415) 625-5600

(702) 388-5099

* * * * * * * * * * * * * * * * * * * * * * * * * * *

INTAKE SECTION (Completed by agency coordinator or other person receiving the complaint)

17. Comments

18. Has the complainant been asked to file this complaint online in NEATS?

Yes

If not, please explain.

19. Name and phone number of person completing this form.

20. Date and time when form is sent to investigative unit.

ORIGINAL TO INVESTIGATOR

NPD-30

5/3/12

Sexual Harassment Or Discrimination Complaint Form Page 4