Discrimination / Discriminatory Harassment Complaint Form
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4DISCRIMINATION / DISCRIMINATORY HARASSMENT COMPLAINT FORM
Michigan Department of Community Health
Complainant’s
2.
3.
4. Employee I.D. Number
Race
Gender
1.
Name (Print or Type)
5. Address
6. City
7. State
8. Zip Code
9. Work Phone
10. Home Phone
11. Bureau/Region/Office/Division
12. Work Hours
(indicate one)
13. Bargaining Unit (
14. Immediate Supervisor
15. Supervisor Work Phone
if applicable)
17. Race
.
r
19. Bureau/Region/Office/Division
ccused
18
Gende
(indicate one)
16. A
Name
20 Accused
21. Bargaining Unit
22. Immediate Supervisor
23. Supervisor Work Phone
Work Phone
24. What is the relationship of the accused to the department? contractual, vendor, employee, etc…_____________________________
25. What is the relationship of the complainant to the department? contractual, vendor, employee, public, etc…_____________________
Discrimination / Discriminatory Harassment Factors
26.
Indicate which factor(s) you believe the actions were based upon. Check all that apply.
Age
Color
Marital Status
Partisan Considerations
Height
Weight
National Origin
Retaliation
Sex
Religion
Race
Sexual Orientation
Disability
Genetic Information
27. Choose Category:
Hostile Work Environment
Quid Pro Quo
Note: Must be due to the above factors.
28. Please list any witnesses and contact information (additional pages may be attached if necessary).
Name
Name
Name
Name
29. Have you discussed this incident with anyone?
No
Yes
If Yes with who and date(s)
30. Have you filed a grievance regarding this situation?
No
Yes
31. Have you asked that the behavior stop?
No
Yes
If Yes, when?
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DCH-1012(E) (6/11) (W)
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