Equal Employment Opportunity And Anti-Harassment Complaint Form printable pdf download

Sheriff’s Department – City of St. Louis

EQUAL EMPLOYMENT OPPORTUNITY AND ANTI-HARASSMENT COMPLAINT FORM

Complaint Number (for Personnel’s use only) __________________

Date _______________

Name _____________________________________________________ Home/Cell Phone ___________________

Street Address ______________________________________________ Work Phone _______________________

City, State, Zip Code _________________________________________________________

Job Title ________________________ Department/Division __________________Work Location__________________

Alleged Discrimination was based on (check appropriate boxes:

Race

[ ]

National Origin/Ancestry

[ ]

Age (40 years and older)

[ ]

Color

[ ]

Disability

[ ]

Religion

[ ]

Sex

[ ]

Retaliation

[ ]

Genetic Information

[ ]

Date of discriminatory took place____________ Earliest_________________ Latest ________________

Check if continuing discrimination or harassment…. [ ]

Explain what discriminatory action was taken against you. Be specific: include dates, names of individual(s) who committed

discriminatory acts, names of any witnesses to the discriminatory action(s), places, etc. for all incidents. Also, include any other

evidence that supports the alleged act(s) of discrimination. If more space is required, use an additional sheet of paper, and be

sure to sign and date each additional sheet of paper used.

________________________________________________________________________________________________________

Have you previously reported any of the discriminatory acts alleged in this complaint to your immediate supervisor, your

appointing authority or designee, or the diversity counselor in your department, and if so, to whom did you report such act(s)

and when did you report such

act(s)?__________________________________________________________________________________________________

________________________________________________________________________________________________________

Resolution Requested:

________________________________________________________________________________________________________

I declare that the above statements are true and accurate to the best of my knowledge, information, and belief.

Signature: _____________________________________________ Date: __________________________

REV 04/2011

Equal Employment Opportunity And Anti-Harassment Complaint Form