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DHR Form EO 001 - Complaint Form <br />County of Hawaii <br />Discrimination /Harassment Complaint Form <br />Name <br />Department <br />Involved <br />I am an ❑ employee of the County ❑ individual <br />Mailing <br />Address <br />E -mail <br />Address <br />Phone # Day Evening V /TDD <br />I prefer to be contacted by (method, time, day, evening): <br />I am filing this complaint because I believe that I was unlawfully discriminated <br />against and /or harassed on the basis of the following (check all that apply): <br />❑ <br />Sex <br />❑ <br />Pregnancy <br />❑ <br />Race <br />❑ <br />Ancestry <br />❑ <br />National Origin <br />❑ <br />Religion <br />❑ <br />Color <br />❑ <br />Disability <br />❑ <br />Age <br />F-1 <br />Genetic Information <br />El <br />Marital Status /Civil <br />Morita <br />F-1 <br />Lactation <br />❑ <br />Military Service <br />❑ <br />Veteran's Status <br />❑ <br />Citizenship <br />❑ <br />Sexual Orientation <br />❑ <br />Gender Identity <br />❑ <br />Gender Expression <br />❑Domestic <br />or Sexual <br />❑ <br />Arrest & Court <br />El <br />Income of <br />Income for Child <br />Violence Victim Status <br />Record' <br />Support Purposes <br />(more on next page) <br />Pursuant to state law, the County may consider an individual's criminal history for employment purposes <br />under certain circumstances. <br />Page 1 of 5 Rev. 02/08/12 <br />