It is the policy of the Department of Housing and Community Development (HCD), as required by federal and state laws, to provide a work environment free of discrimination. Please refer to HCD’s Equal Employment Opportunity (EEO) policies for more information. This form may be used by HCD employees or job applicants applying for a position within HCD. To initiate a complaint of discrimination within HCD, this form must be filed with the EEO Office within 365 days of the last act of discrimination. When filing a complaint, HCD employees have a right to confidentiality to the extent possible. Any form of retaliation against an employee for filing a complaint may be cause for disciplinary action. INFORMATION: I. COMPLAINANT’S Race/Ethnicity (optional) Age (optional) Gender (optional) Complainant’s Name Classification Job Title Division/Branch/Unit Immediate Supervisor Work Mailing Address Work Phone Number Home Mailing Address Home Phone Number Personal E-mail Address (optional) Date(s) of Discriminatory Treatment Date of Last Discriminatory Act - PERSON(S) AGAINST WHOM YOU ARE FILING A COMPLAINT II. RESPONDENT’S INFORMATION (If more than one respondent list others under Section V): Name Classification Respondent’s Work Location Work Phone Number Relationship To Complainant Respondent’s III. BASIS FOR COMPLAINT - PROTECTED GROUP CATEGORY: [Check appropriate box(es)] Age (40 or older) Medical Condition (cancer related or genetic characteristics) Ancestry National Origin Color Political Affiliation Denial of Family and/or Medical Care Leave Race Denial of Pregnancy Disability Leave Religion Denial of Reasonable Accommodation Retaliation (reprisal) Disability (physical or mental) Sex (including sexual harassment or pregnancy) Gender (including gender identity/expression) Sexual Orientation Genetic Information Veteran Status/Military Leave Marital Status Other (specify)
It is the policy of the Department of Housing and Community Development (HCD), as required by federal and state laws, to provide a work environment free of discrimination. Please refer to HCD’s Equal Employment Opportunity (EEO) policies for more information. This form may be used by HCD employees or job applicants applying for a position within HCD. To initiate a complaint of discrimination within HCD, this form must be filed with the EEO Office within 365 days of the last act of discrimination. When filing a complaint, HCD employees have a right to confidentiality to the extent possible. Any form of retaliation against an employee for filing a complaint may be cause for disciplinary action. I. COMPLAINANT’S INFORMATION: Complainant’s Name Race/Ethnicity (optional) Age (optional) Gender (optional) Classification Job Title Division/Branch/Unit Immediate Supervisor Work Mailing Address Work Phone Number Home Mailing Address Home Phone Number Personal E-mail Address (optional) Date(s) of Discriminatory Treatment Date of Last Discriminatory Act II. RESPONDENT’S INFORMATION - PERSON(S) AGAINST WHOM YOU ARE FILING A COMPLAINT (If more than one respondent list others under Section V): Respondent’s Name Classification Work Location Work Phone Number Respondent’s Relationship To Complainant III. BASIS FOR COMPLAINT - PROTECTED GROUP CATEGORY: [Check appropriate box(es)] Age (40 or older) Ancestry Color Denial of Family and/or Medical Care Leave Denial of Pregnancy Disability Leave Denial of Reasonable Accommodation Disability (physical or mental) Gender (including gender identity/expression) Genetic Information Marital Status Medical Condition (cancer related or genetic characteristics) National Origin Political Affiliation Race Religion Retaliation (reprisal) Sex (including sexual harassment or pregnancy) Sexual Orientation Veteran Status/Military Leave Other (specify)
HCD-DIR-8-DiscriminationComplaintForm_REV%206-15.docx