Discrimination / Discriminatory Harassment Complaint Form (Page 3 of 4) in pdf

Discrimination / Discriminatory Harassment Complaint Report Instructions

General Instructions

This form may be downloaded from the Intranet and must be completed by MDCH employees, customers, contractors,

vendors, or members of the public who wish to file an internal complaint of potential violations of Discriminatory Harassment.

Assistance in completing this form may be obtained from a harassment coordinator, supervisor, union steward, or the Equal

Employment Opportunity Officer. Please ensure that the following information is submitted promptly following the alleged

event, and record all information so that it is legible using type or block print.

1. Complete items 1-32.

2. Attach additional pages describing the alleged event(s).

3. Sign and date the form and any additional documents submitted.

4. Make a copy for your records.

5. Forward your complaint of Discriminatory Harassment to:

Central Office send to EEO Officer.

Hospitals and Centers send to Harassment Coordinator, Hospital Director or EEO Officer.

6. Submit your complaint to the appropriate authority as soon as practicable after the alleged violation(s).

7. Refer to Discriminatory Harassment Policy DCH 4.1.13 for more information.

Investigative Process

A thorough investigation shall be conducted on all legitimate complaints of discriminatory harassment. The complainant shall

provide the following information to the investigator to determine whether a full-scale investigation is warranted:

1. Specific details as to what happened

2. Who was directly or indirectly involved

3. When the incident(s) occurred (date and time)

4. Witnesses to the event(s)

5. Documents or other evidence that may be useful to the investigation

6. Why the complainant believes that their protected status, i.e. race, gender, age, etc., is the reason for the adverse

action(s) or conduct

7. How the treatment of the complainant differs from the treatment of other similarly situated employees who do not

share the complainant’s protected status.

Retaliation Warning

Retaliation against anyone making a complaint, complained about discrimination/discriminatory behavior, or participation in the

investigation is a violation of law and department policy, and is strictly prohibited. Retaliation complaints shall be investigated

as a separate charge and persons found in violation may be subjected to discipline up to and including discharge.

To file a Retaliation Complaint you must have:

1) Filed a Discrimination/Discriminatory Harassment Complaint

2) Verbally expressed or complained about Discrimination/Discriminatory Harassment

3) Participated in a Discriminatory Harassment Investigation (such as a witness)

If you were involved in one of above (1-3) activities, now you are experiencing negative actions in the work place which you feel

is related to one of the above (1-3) activities, you can file a retaliation complaint. There must be a connection between your

participation in the Discrimination/Discriminatory Harassment Process or your opposition to Discrimination/Discriminatory

behaviors and the negative actions that you are experiencing at work. You will need to show a before and after effect; a

difference in treatment after being involved in the complaint process.

Additional Assistance and Information

The Michigan Department of Community Health has an obligation to investigate complaints and take appropriate action even if

the complainant does not wish to proceed with an internal investigation. The complainant’s identity and complaint may be

subjected to disclosure pursuant to the investigation and resolution of the complaint.

You may also file an external complaint with the Michigan Department of Civil Rights within 180 days of the alleged incident;

the federal Equal Employment Opportunity Commission within 300 days of the alleged incident; a grievance through your union

or Civil Service; or file a private civil suit.

Information contained in this form will be kept confidential to the extent allowed by law, and as is practical to conduct a

complete and thorough investigation.

If you have questions regarding this form or the investigative process, please contact Toya Williams EEO Officer for MDCH at

517-335-4276 or Joseph Collins, Human Resources Director at 517-241-0228.

Page 3 of 4

DCH-1012(E) (6/11) (W)

Discrimination / Discriminatory Harassment Complaint Form Page 3

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