6. LOCATION OF POSITION: (If different from 4) (Reasons) 7. CHECK BELOW THE BASES FOR ALLEGED DISCRIMINATION: (Check Your Race) R RACE African American Caucasian American Indian/Alaskan Native Asian Pacific Islander Hispanic Latino A (State Your Age) AGE DOB S SEX (Check Your Sex) Male Female H (Check Your Appropriate Basis) HARASSMENT Sexual Non- Sexual (State Your National Origin) (Specify) NATIONAL ORIGIN Hispanic Other N C (State Your Color) H HANDICAP (State Your Handicap) Mental Physical L (State Your Religion) RELIGION (Based Upon EO/EEO Activity) O RETALIATION Yes No 8. ARE YOU BEING REPRESENTED: 9. IF YES, NAME OF REPRESENTATIVE: (Complete 9) Yes No Attorney at Law Yes No 10. I have have not filed a grievance on this matter. 11. I have have not appealed a grievance on this matter. 12. WHAT CORRECTIVE ACTION DO YOU WANT TAKEN TO RESOLVE YOUR COMPLAINT? (Explain how you believe you were discriminated against) SPECIFIC ALLEGATION AND ISSUES: Issues A. Number each issue. List briefly the alleged act of discrimination, the basis, and the date(s) it took place. Optional: You may indicate the name of the individual you believe discriminated against you. SAMPLE: 1. I was discriminated against on (date) on the basis of (Race, Religion, or other Basis) when (briefly list the discrimination event(s) or personnel action).
6. LOCATION OF POSITION: (If different from 4) 7. CHECK BELOW THE BASES (Reasons) FOR ALLEGED DISCRIMINATION: R RACE (Check Your Race) African American Caucasian American Indian/Alaskan Native Asian Pacific Islander Hispanic Latino A AGE (State Your Age) DOB S SEX (Check Your Sex) Male Female H HARASSMENT (Check Your Appropriate Basis) Sexual Non- Sexual N NATIONAL ORIGIN (State Your National Origin) Hispanic Other (Specify) C (State Your Color) H HANDICAP (State Your Handicap) Mental Physical L RELIGION (State Your Religion) O RETALIATION (Based Upon EO/EEO Activity) Yes No 8. ARE YOU BEING REPRESENTED: Yes (Complete 9) No 9. IF YES, NAME OF REPRESENTATIVE: Attorney at Law Yes No 10. I have have not filed a grievance on this matter. 11. I have have not appealed a grievance on this matter. 12. WHAT CORRECTIVE ACTION DO YOU WANT TAKEN TO RESOLVE YOUR COMPLAINT? SPECIFIC ALLEGATION AND ISSUES: (Explain how you believe you were discriminated against) Issues A. Number each issue. List briefly the alleged act of discrimination, the basis, and the date(s) it took place. Optional: You may indicate the name of the individual you believe discriminated against you. SAMPLE: 1. I was discriminated against on (date) on the basis of (Race, Religion, or other Basis) when (briefly list the discrimination event(s) or personnel action).
ngbform713_5_r.docx