Department Of Public Health And Human Services Complaint Resolution Form Page 2
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1
2Statement:
Please describe the incident(s) as clearly and concisely as possible. Provide as much detail as you can recall,
including when and where the events occurred and who said what to whom. Explain why you believe the conduct
or treatment was discriminatory. Use additional pages, if necessary.
Action Sought:
Please describe what you would like to see done to correct the situation.
Complaint Authorization:
I understand that complete confidentiality cannot be maintained in the process of handling informal and formal
complaints. I agree that this statement of allegations may be used during the investigation of the case. I further
consent that this statement and certain information in the complaint file may be disclosed to certain agency
employees including the person I believe discriminated against me in order to resolve my complaint, conduct fact
finding, or implement remedial action. I also understand that information may be disclosed if required by law,
rule, regulation, or court order. I affirm that this complaint statement is true, accurate, and complete to the best of
my knowledge.
________________________________
_____________________
Signature of Complainant
Date
In addition to, or in lieu of, filing a complaint of unlawful discrimination or retaliation under this complaint
process, individuals may file a complaint with an applicable state or federal agency. Jurisdiction may vary based on
the nature of the complaint. For advice, assistance and an explanation of filing deadlines, individuals may contact
the following:
Department of Public Health and Human
Montana Human Rights Bureau (HRB)
1625 11
Avenue
th
Services (DPHHS)
P. O. Box 1728
Office of Human Resources
Helena, MT 59624
Civil Rights/EEO Specialist
Phone: (800) 542-0807
P.O. Box 4210
Phone: (406) 444-2884
Helena, MT 59604
Fax: (406) 444-2798
Phone: (406) 444-1386
TTY: (406) 444-0532
Fax: (406) 444-0262
V, TTY: (800) 833-8503
V, TTY: (406) 444-1335
Office for Civil Rights (OCR)
United States Equal Employment Opportunity
U.S. Department of Health and Human Services
Commission (EEOC)
999 18th Street, Suite 417
Federal Office Building
Denver, CO 80202
909 First Avenue, Suite 400
Voice Phone: (800) 368-1019
Seattle, WA 98104-1061
Fax: (303) 844-2025
Phone: (800) 669-4000
TDD: (800) 537-7697
Fax: (206) 220-6911
TTY: (800) 669-6820
Page 2 of 2
Revised 10/21/2013
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