1.03f EEO Appeal Form - Exhibit

Document Type: Exhibit
Number: 1.03f
Effective: 07-13-09
Revised: 08-01-14
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

Appeal Form

Directions: If the complainant or respondent is dissatisfied with the resolution of the
discrimination/harassment matter, the employee may within five (5) work days of
receiving the resolution letter, file a formal appeal with Human Resources using this
form. Please see the Equal Employment Regulation for a full description of the appeal
process. The formal appeal shall include a copy of the original complaint and resolution.
Attach additional sheets as necessary.

Employee Name:


Work Location:

Employee Representative (if applicable):

Immediate Supervisor:

Date of original complaint:

Date resolution received:

Brief summary of original complaint and resolution:

Statement of why the employee disagrees with the resolution:

Explain how the alleged harassment and/or discrimination is or is not based on the
employee’s race, color, religion, gender, age, national origin, sexual orientation, gender identity, disability, or veteran status:

Remedy Sought:

Employee Signature:


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