Department Of Public Health And Human Services Complaint Resolution Form
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1
2State of Montana
Department of Public Health and Human Services
Complaint Resolution Form
Alternative accessible formats of this document are available on request.
Complainant’s Name:
__________
____
______________
(First)
(Middle)
(Last)
______
___________
Mailing Address:
__________________
(Street)
(P.O. Box)
_____________________
_____________
________
(City)
(ST)
(Zip Code)
Phone Number:
_____________
___________
________
(Home)
(Work)
(Cell)
Complainant’s Status:
Employee
Job Applicant
Department Customer
Interested Person
Basis of Complaint:
Race
Color
Genetic Information
Retaliation
Creed
Age
National Origin
Political Belief
Religion
Physical or Mental Disability
Sexual Orientation
Marital Status
Sex
Veteran Status
Social Origin or Condition
Ancestry
Culture
Name of person you believe discriminated against you:
____________________________
Department or Address:
_____________________________
Phone:
_______________________
Date:
______ Time:
_____ Place of the incident(s):
_____________________
Documentation:
Please attach copies of any documents or material you believe are relevant.
Witnesses:
Did anyone witness the incident(s) of discrimination?
Yes
No If so, please list names and phone numbers of
any witnesses to the incident(s). Use additional pages if necessary.
Name:
Phone:
_
Name:
Phone:
_
Name:
Phone:
_
Page 1 of 2
Revised 10/21/2013
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Parent category: Legal