□ Genetic Information □ Retaliation □ National Origin □ Political Relief

Department or Address: ___

Name of person you believe discriminated against you: ___

Employees, job applicants, and customers may use this form to file an internal complaint based on discrimination or harassment (including a hostile work environment) based on any of the protected classes identified in this form. Individuals should submit this form to the agency where the event is believed to have occurred.

Complainant's Name:

Mailing Address:

Phone:

Complainant's Status:

☐ Employee ☐ Job Applicant ☐ Department Customer

Basis of Complaint:

☐ Race ☐ Color ☐ Genetic Information ☐ Retaliation

☐ Sex ☐ Age ☐ National Origin ☐ Political Belief

☐ Religion ☐ Physical/Mental Disability ☐ Sexual Orientation ☐ Marital Status

☐ Creed ☐ Military Service ☐ Veteran Status ☐ Ancestry

☐ Pregnancy, Child Birth, or a Medical Condition Related to Pregnancy or Childbirth ☐ Gender Identity or Expression ☐ Social Origin or Condition