HomeMy WebLinkAboutDHR Form EO 001-Complaint FormDHR Form EO 001 - Complaint Form
County of Hawaii
Discrimination /Harassment Complaint Form
Name
Department
Involved
I am an ❑ employee of the County ❑ individual
Mailing
Address
E -mail
Address
Phone # Day Evening V /TDD
I prefer to be contacted by (method, time, day, evening):
I am filing this complaint because I believe that I was unlawfully discriminated
against and /or harassed on the basis of the following (check all that apply):
❑
Sex
❑
Pregnancy
❑
Race
❑
Ancestry
❑
National Origin
❑
Religion
❑
Color
❑
Disability
❑
Age
F-1
Genetic Information
El
Marital Status /Civil
Morita
F-1
Lactation
❑
Military Service
❑
Veteran's Status
❑
Citizenship
❑
Sexual Orientation
❑
Gender Identity
❑
Gender Expression
❑Domestic
or Sexual
❑
Arrest & Court
El
Income of
Income for Child
Violence Victim Status
Record'
Support Purposes
(more on next page)
Pursuant to state law, the County may consider an individual's criminal history for employment purposes
under certain circumstances.
Page 1 of 5 Rev. 02/08/12
DHR Form EO 001 - Complaint Form
(Please use additional sheets as necessary)
❑ Retaliation (please indicate below):
❑ I filed a complaint under the Anti - Discrimination and Harassment
Policy on (date).
❑ I requested a reasonable accommodation based on
on (date).
❑ Other (please identify):
I believe I was discriminated against in
❑ my employment status with the ❑ a program or service which the
County, or County provides.
Complaint Allegations
Date occurred:
Location:
Please describe what happened:
Time:
Who was involved? (Names and other identifying information)
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DHR Form EO 001 - Complaint Form
(Please use additional sheets as necessary)
Names and contact information of any witnesses:
Please explain why you believe the above - described incident(s) violates the
County's Anti - Discrimination and Harassment Policy.
Is there any other information /evidence you believe would help us in our
investigation and review of this matter?
What resolution(s) to your complaint would you like the County to consider?
Page 3 of 5 Rev. 02/08/12
DHR Form EO 001- Complaint Form
(Please use additional sheets as necessary)
I have provided the above information in oral and /or written form. To the best of
my knowledge, information, and belief, every statement contained herein is true
and no statement is misleading.
Print Name
Date
Signature
Page 4 of 5 Rev. 02/08/12
DHR Form EO 001 - Complaint Form
(Please use additional sheets as necessary)
County Use Only
ACTIONS TAKEN
Date Action Initials
DISPOSITON
Date:
Status:
Page 5 of 5 Rev. 02/08/12