1.03e EEO Complaint Form - Exhibit

Document Type: Exhibit
Number: 1.03e
Effective: 07-13-09
Revised: 01-04-12
Legal Reference: I.C. § 67-5901
20 U.S.C. § 1703
29 U.S.C. § 794
38 U.S.C. § 4211
42 U.S.C. § 2000
42 U.S.C. § 12101

Complaint Form

Directions: To be completed by the complaining employee (“complainant”).

Name of Complainant:

Name of Alleged Harasser(s):

Do you think you have been harassed or discriminated against based on your race, color, religion, gender, age, national origin, genetic information, sexual orientation, gender identity/expression, disability, or veteran status?

If yes, which of the above personal characteristics do you believe is the basis for the
harassment or discrimination?

If no, what is the basis of your complaint?

Please describe in detail the actions and/or events the lead to this complaint:

Who was involved?

Who witnessed the event(s)?

Where did the event take place?

What date(s) and time(s) did the action take place?

What was said or done? By whom?

Has anything similar happened previously? If yes, please explain:

How has this action or event affected you?

How would you like to have this complaint resolved?

List any additional information that might be helpful in investigating this matter.

Complainant’s Signature:

Date Complaint Submitted:

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