OFFICE OF STATE HUMAN RESOURCES
This form will provide preliminary information in order to assist in the initial review of your complaint. Name: FORMTEXT ?????Home Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Home Phone: FORMTEXT ?????Agency/Division: FORMTEXT ?????Work Phone: FORMTEXT ?????Work Location/Facility: FORMTEXT ?????Please select your current status: FORMCHECKBOX Career State Employee FORMCHECKBOX FORMCHECKBOX Former Career State Employee FORMCHECKBOX Probationary State Employee FORMCHECKBOX Former Probationary State Employee FORMCHECKBOX Applicant for State Employment Shift or Normal Work Schedule: FORMTEXT ?????Email Address: FORMTEXT ?????Position Title: FORMTEXT ?????Gender: FORMCHECKBOX Male FORMCHECKBOX FemaleRace: FORMCHECKBOX Black FORMCHECKBOX Asian/Pacific Islander FORMCHECKBOX American Indian FORMCHECKBOX White FORMCHECKBOX Alaskan Native 52768514414500 FORMCHECKBOX Other FORMTEXT ?????Ethnicity: FORMCHECKBOX Hispanic FORMCHECKBOX Non-Hispanic Immediate Supervisor Name: FORMTEXT ????? Telephone Number: FORMTEXT ????? I believe that I was discriminated against by the following: (Check those that apply) FORMCHECKBOX Agency FORMCHECKBOX Supervisor FORMCHECKBOX Other (Please Specify) FORMTEXT ?????4253865698500Full Name/Agency you believe discriminated against you: FORMTEXT ?????Position/Title (if applicable) FORMTEXT ?????Address: FORMTEXT ?????Telephone Number: FORMTEXT ????? Most recent date of alleged unlawful action: FORMTEXT ????? Type of unlawful action (must select one): FORMCHECKBOX Discrimination FORMCHECKBOX Harassment FORMCHECKBOX RetaliationIf alleging discrimination or retaliation, check alleged unlawful action: FORMCHECKBOX Hiring FORMCHECKBOX Training FORMCHECKBOX Work Assignments FORMCHECKBOX Demotion FORMCHECKBOX Suspension without Pay FORMCHECKBOX Promotions FORMCHECKBOX Dismissal FORMCHECKBOX Compensation FORMCHECKBOX Overall Performance Ratings FORMCHECKBOX Reduction in ForceDiscrimination Basis: Do you think this happened to you because of (check as appropriate):547306528003500 FORMCHECKBOX Race FORMCHECKBOX Sex FORMCHECKBOX National Origin FORMCHECKBOX Disability FORMCHECKBOX Political Affiliation FORMCHECKBOX Color FORMCHECKBOX Religion FORMCHECKBOX Genetic Information FORMCHECKBOX Age(40+) FORMCHECKBOX Other (Please Specify) FORMTEXT ?????What remedy or resolution are you seeking? FORMTEXT ?????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). FORMTEXT ?????List Names and Nature of Witnesses:(1st) Witness Name Contact Information FORMTEXT ????? FORMTEXT ????? Information (1st ) Witness Can Provide: FORMTEXT ????? (2nd) Witness Name Contact Information FORMTEXT ????? FORMTEXT ?????(Information (2nd) Witness Can Provide: FORMTEXT ?????Information (2nd) Witness Can Provide: 4381513271500357759013144500 Complainant Name (print) Complainant Signature Date 3577590190500438151143000EEO Representative Name (print) EEO Representative Date of Receipt5715002857500 For Grievances in Regard to Harassment, Discrimination, and/or Retaliation:The Grievance Officer will conduct an Equal Opportunity Informal Inquiry or investigation into your claims. The Informal Inquiry should be completed within 45 calendar days. If you are not satisfied with the written response from the Informal Inquiry, you have fifteen (15) calendar days from the date you receive the written response from the Informal Inquiry to submit an “SPA Grievance Supplemental Filing Form” to Employee Relations in order to continue the grievance process.STATEMENT ON NON-RETALIATION Employees have the right to use this procedure free from threats or acts of retaliation, interference, coercion, restraint, discrimination, or reprisal. Employees may not be retaliated against for participating in a grievance as a grievant, a respondent, a witness, or as a grievance panel member. If you feel you have been retaliated against for filing a grievance please contact a Grievance Officer and report the matter so the appropriate action may be taken.grievant certificationI hereby certify that all information submitted on this “EEO Informal Complaint Intake Form” and any supporting documentation is true, complete to the best of my knowledge and belief, and filed in good faith. I understand that I must continue to meet the performance and conduct expectations of my employment during this grievance process.Signature:Date:Mail this form to: Employee Relations, UNC Charlotte Office of Human Resources, 9201 University City Blvd, Charlotte, NC 28223-0001.OR Fax this form to: Employee Relations at 704-687-5255.OR Deliver this form to: Employee Relations, King Building 113/ Office of Human Resources (Main Office), King Building 22234544008293100004171950893445035623508324850 ................
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