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City of St. Louis Department of Personnel Administrative Regulation NO. 103 and 113 - Form |
The City of St. Louis Administrative Regulations have been converted to electronic format by the staff of the St. Louis Public Library. This electronic version has been done for the interest and convenience of the user. These are unofficial versions and should be used as unofficial copies.
Official printed copies of the City of St. Louis Administrative Regulations may be obtained from the Personnel Office at 1114 Market Street, Room 703, St. Louis, Missouri 63101.
EQUAL EMPLOYMENT OPPORTUNITY COMPLAINT
Complaint Number (for Personnel's use only) __________________ Date _______________
Name __________________________________ Home/Cell Phone ___________________
Street Address _________________________________ Work Phone _________________
City, State, Zip Code _________________________________________________________
Job Title ________________________ Department/Division _______________________________
Alleged Discrimination was based on (check appropriate box/boxes):
Race or Color….[ ] National
Origin/Ancestry….[ ]
Age (40 years or older)….[ ] Disability….[ ]
Religion….[ ] Sex….[ ] Sexual Orientation….[ ] Gender Identity or Expression….[ ]
Marital Status….[ ] Retaliation….[ ] Sexual Harassment….[
] Genetic Information….[
]
Date of most recent discriminatory act: ________________________________________
Check if continuing discrimination….[ ]
Explain what discriminatory action was taken against you. Be specific: include dates, names of individual(s) who committed discriminatory acts, names of any witnesses to the discriminatory action(s), places, etc. for all incidents. Also, include any other evidence that supports the alleged act(s) of discrimination. If more space is required, use an additional sheet of paper, and be sure to sign and date each additional sheet of paper used.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Have you previously reported any of the discriminatory acts alleged in this complaint to your immediate supervisor, your appointing authority or designee, or the diversity counselor in your department, and if so, to whom did you report such act(s) and when did you report such act(s)?
__________________________________________________________________________
Resolution Requested: __________________________________________________________________________
__________________________________________________________________________
I declare that the above statements are true and accurate to the best of my knowledge, information, and belief.
Signature: ________________________________ Date: __________________________
REV 01/11
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