Employment Discrimination Complaint Form (Page 2 of 3) in pdf

Employment Discrimination Complaint Form Page 2

STATE OF ALASKA

Page 2 of 3

Month: __________________ Day: ______________________ Year:________________

(Note: Discrimination must be ongoing or must have occurred within 90 days

of the complaint filing to utilize the OEEO informal complaint process)

VI. OTHER COMPLAINT INFORMATION

Have you filed this complaint with the Alaska State Commission for

Human Rights or the federal Equal Employment Opportunity Commission?

Yes _____ No _____

Have you filed this complaint through a collective bargaining agreement

union process? If so, please give the date filed and current step of the

grievance. Date: ____________ Step: ________

Have you consulted with an attorney? Yes _____ No______

VII. BRIEFLY DESCRIBE INCIDENTS YOU BELIEVE WERE ACTS AND/OR WORDS OF

DISCRIMINATION.

INCLUDE NAMES AND DATES. ATTACH SUPPORTING DOCUMENTATION,

IF AVAILABLE. ATTACH ADDITIONAL SHEETS AS NEEDED.

(Note: You are responsible for retaining copies of the information you

provide the OEEO. All information received by this office becomes property

of the office and will not be returned.)

___________________________________________________________________________

VIII. IN WHAT WAY WOULD YOU LIKE TO SEE THIS MATTER RESOLVED?

ATTACH

ADDITIONAL SHEETS AS NEEDED.

___________________________________________________________________________

I affirm that all statements regarding this alleged incident of

discrimination are true and factual to the best of my knowledge.

Complainant's signature: ________________________ Date: ________

All information received by the Office of Equal Employment Opportunity

during the course of a complaint investigation is confidential and will

not be provided to unions or other investigative agencies.

State of Alaska

Office of the Governor

Office of Equal Employment Opportunity

Employment Discrimination Complaint Form Page 2