OFFICE OF STATE HUMAN RESOURCES



EEO INFORMAL COMPLAINT INTAKE FORMThis form will provide preliminary information in order to assist in the initial review of your complaint. Name:Home Address:City:State:Zip:Home Phone:Agency/Division:Work Phone:Work Location/Facility: Please select your current status:3763645419108890036830171704042545 Career State Employee Former Career State Employee Probationary State Employee 2503805552458445555245 Former Probationary State Employee Applicant for State Employment Shift or Normal Work Schedule:Email Address:Position Title:107188050805480055080Gender: Male FemaleRace:81915-2540 Black8191531750 Asian/Pacific Islander 8826540640 American Indian685808890 White6858025400 Alaskan Native 6858029845 Other_____________50800147320Ethnicity: Hispanic444508255 Non-Hispanic Immediate Supervisor Name: Telephone Number: I believe that I was discriminated against by the following: (Check those that apply)1553845552452742565647704699057150 Agency Supervisor Other (Please Specify)__________________________________Full Name/Agency you believe discriminated against you:Position/Title (if applicable) Address:Telephone Number: Most recent date of alleged unlawful action:244284573025484949573025369062073025 Type of unlawful action (must select one): Discrimination Harassment RetaliationIf alleging discrimination or retaliation, check alleged unlawful action: 438155651539490656477030060906477017011656477092202055245 Hiring Training Work Assignments Demotion Suspension without Pay496824066040482605651530029157556517011656604092202046990 Promotions Dismissal Compensation Overall Performance Ratings Reduction in Force Discrimination Basis: Do you think this happened to you because of (check as appropriate):402907515176542100506354762516510039370114301894205-254000970915101600032931101587500 RaceSexNational Origin Disability Political Affiliation ColorReligionGenetic Information Age(40+) Other (Please Specify)_______________What remedy or resolution are you seeking?In your own words, briefly describe what happened to you that you believe to be discriminatory. (Use additional pages as needed. Please print clearly or type).List Names and Nature of Witnesses:____________________________________ _______________________________________(1st) Witness Name Contact Information Information (1st ) Witness Can Provide:____________________________________ _______________________________________(2nd) Witness Name Contact InformationInformation (2nd) Witness Can Provide: CLAIMS____________________________________ ______________________________________ Complainant Name (print) Complainant Signature Date ____________________________________ ______________________________________EEO Representative Name (print) EEO Representative Date of Receipt5715002857500 NC Office of State Human Resources Complaint Intake Form Revision: 1/17/143454400829310000417195089344503562350832485021717006162040001885950664845020383506800850862331655129500132207064376300011696706285230001017270613283000864870598043000712470582803000 ................
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