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Montana state government encourages employees, applicants, clients, and customers who believe they have been discriminated against or harassed to contact agency management or the agency's equal opportunity (EO) officer, American's with Disabilities Act (ADA) Coordinator, or human resources (HR) staff.

Montana state government prohibits retaliation against employees, applicants, clients, and customers who oppose unlawful discriminatory practices, files a discrimination complaint, or participates in a discrimination proceeding, including testifying in court.

State agencies are committed to resolving complaints of discrimination and harassment in a fair, timely, and impartial manner. Employees, applicants, clients, and customers may file a complaint under the state's complaint resolution procedures if they believe they have experienced discrimination, harassment, or retaliation. Complainants are encouraged to use the Department of Administration's complaint form found at http://hr.mt.gov/newresources.

Montana state government is committed to providing equal access to employment, programs, services, and activities, and prohibits discrimination and harassment based on race, color, national origin, age, physical or mental disability, marital status, religion, creed, sex, pregnancy, childbirth or a medical condition related to pregnancy or childbirth, sexual orientation, gender identity or expression, political beliefs, genetic information, military service or veteran's status, culture, social origin or condition, or ancestry unless based on a bona fide occupational qualification (BFOQ).

Service members and veterans may submit a formal, online complaint with VETS at http://webapps.dol.gov/elaws/vets/userra/1010.asp.

An applicant, client, customer, or employee may concurrently file a complaint of unlawful discrimination with:

□ 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

Please describe what you would like to see done to correct the situation.

Please describe the incident(s) as clearly and concisely as possible. Provide as much detail as you can recall, including when and where the events occurred and who said what to whom. Explain why you believe the conduct or treatment was discriminatory. Use additional pages, if necessary.

Name: ___ Phone: ___ Name: ___ Phone: ___

numbers of any witnesses to the incident(s). Use additional pages, if necessary.

-end of form

In addition to the internal complaint process, complaints may be filed with the following agencies:

Signature of Complainant

Date

I affirm that this complaint statement is true, accurate, and complete to the best of my knowledge.

remedial action. I also understand that information may also be disclosed if required by law, rule, regulation, or court order.