Form AA-100 Affirmative Action Grievance Form - Connecticut

Form AA-100 is a Connecticut Department of Mental Health & Addiction Services form also known as the "Affirmative Action Grievance Form". The latest edition of the form was released in July 12, 2018 and is available for digital filing.

Download an up-to-date Form AA-100 in PDF-format down below or look it up on the Connecticut Department of Mental Health & Addiction Services Forms website.

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FORM
DEPARTMENT OF MENTAL HEALTH & ADDICTION SERVICES
AA-100
Affirmative Action Grievance Form
Please complete the following:
Last Name:
First Name:
Facility:
Location/
Division:
Race:
Sex:
Shift:
Days/Week:
Position Title:
Immediate Supervisor
Name and Title:
Work#:
Telephone number(s) where you can be reached:
Home #:
Cell#:
E-mail:
Work Address
Home Address
Mailing Preference (check which you prefer):
Work Address:
Home Address:
(Street, City, State, Zip)
If you prefer mail to your home address, please submit on a
separate sheet. This information will be kept confidential.
Please check any applicable items below:
I believe that on ______________ (mm/dd/yyyy) I have been:
Discriminated Against
Harassed
(Incident Date)
On the basis of:
RACE
COLOR
RELIGIOUS CREED
AGE (DOB:_________________________________)
SEX
SEXUAL HARASSMENT
GENDER IDENTITY OR EXPRESSION
MARITAL STATUS
NATIONAL ORIGIN
ANCESTRY
PRESENT / PAST HISTORY OF MENTAL DISABILITY
SEXUAL ORIENTATION
INTELLECTUAL DISABILITY
LEARNING DISABILITY OR PHYSICAL DISABILITY INCLUDING, BUT NOT LIMITED TO, BLINDNESS
PREGNANCY/ FAMILIAL STATUS
GENETIC INFORMATION
PRIOR CONVICTION OF A CRIME (subject to Sec. 46a-79, 46a-80 of C.G.S.)
VETERAN STATUS
*COMPLETE THE FOLLOWING, ONLY IF APPLICABLE:
I believe that on ________(mm/dd/yyyy) I was retaliated against by ________________________________ (name) for
previously opposing a discriminatory practice (Filing or testifying in an Affirmative Action Grievance, CHRO or EEOC
grievance).
How was your employment affected? (check any that apply)
FAILURE TO HIRE
FAILURE TO PROMOTE
DEMOTION
TERMINATION
SUSPENSION OR OTHER CORRECTIVE ACTION
POOR SERVICE RATING
DENIAL OF TRAINING OR ACCOMMODATION
UNEQUAL TREATMENT (PLEASE DESCRIBE): ___________
____________________________________________________________________________________________________________________________
Please complete page 2 and attach to this form, along with any other documentation.
I elect to resolve this through mediation if possible
(Only in cases with no MHAS-20 Work Rule Violation or Affirmative Action investigations)
By signing below, I understand that I have the right to file my complaint with the Commission on Human Rights & Opportunities (CHRO), and/or
the U.S. Equal Employment Opportunity Commission (EEOC), or with any other state, federal or local agency that enforces laws against
discriminatory or illegal employment practices. I certify that the information provided herein is true to the best of my knowledge and belief:
Signature of Complainant
Date
REV. 7/12/18
AA GRIEVANCE FORM AA-100
PAGE 1 OF 2
FORM
DEPARTMENT OF MENTAL HEALTH & ADDICTION SERVICES
AA-100
Affirmative Action Grievance Form
Please complete the following:
Last Name:
First Name:
Facility:
Location/
Division:
Race:
Sex:
Shift:
Days/Week:
Position Title:
Immediate Supervisor
Name and Title:
Work#:
Telephone number(s) where you can be reached:
Home #:
Cell#:
E-mail:
Work Address
Home Address
Mailing Preference (check which you prefer):
Work Address:
Home Address:
(Street, City, State, Zip)
If you prefer mail to your home address, please submit on a
separate sheet. This information will be kept confidential.
Please check any applicable items below:
I believe that on ______________ (mm/dd/yyyy) I have been:
Discriminated Against
Harassed
(Incident Date)
On the basis of:
RACE
COLOR
RELIGIOUS CREED
AGE (DOB:_________________________________)
SEX
SEXUAL HARASSMENT
GENDER IDENTITY OR EXPRESSION
MARITAL STATUS
NATIONAL ORIGIN
ANCESTRY
PRESENT / PAST HISTORY OF MENTAL DISABILITY
SEXUAL ORIENTATION
INTELLECTUAL DISABILITY
LEARNING DISABILITY OR PHYSICAL DISABILITY INCLUDING, BUT NOT LIMITED TO, BLINDNESS
PREGNANCY/ FAMILIAL STATUS
GENETIC INFORMATION
PRIOR CONVICTION OF A CRIME (subject to Sec. 46a-79, 46a-80 of C.G.S.)
VETERAN STATUS
*COMPLETE THE FOLLOWING, ONLY IF APPLICABLE:
I believe that on ________(mm/dd/yyyy) I was retaliated against by ________________________________ (name) for
previously opposing a discriminatory practice (Filing or testifying in an Affirmative Action Grievance, CHRO or EEOC
grievance).
How was your employment affected? (check any that apply)
FAILURE TO HIRE
FAILURE TO PROMOTE
DEMOTION
TERMINATION
SUSPENSION OR OTHER CORRECTIVE ACTION
POOR SERVICE RATING
DENIAL OF TRAINING OR ACCOMMODATION
UNEQUAL TREATMENT (PLEASE DESCRIBE): ___________
____________________________________________________________________________________________________________________________
Please complete page 2 and attach to this form, along with any other documentation.
I elect to resolve this through mediation if possible
(Only in cases with no MHAS-20 Work Rule Violation or Affirmative Action investigations)
By signing below, I understand that I have the right to file my complaint with the Commission on Human Rights & Opportunities (CHRO), and/or
the U.S. Equal Employment Opportunity Commission (EEOC), or with any other state, federal or local agency that enforces laws against
discriminatory or illegal employment practices. I certify that the information provided herein is true to the best of my knowledge and belief:
Signature of Complainant
Date
REV. 7/12/18
AA GRIEVANCE FORM AA-100
PAGE 1 OF 2
FORM
DEPARTMENT OF MENTAL HEALTH & ADDICTION SERVICES
AA-100
Affirmative Action Grievance Form
Alleged Violator(s) / Respondent(s): (use separate paper if more space is needed)
NAME
TITLE
UNIT
PHONE #
SHIFT
Witnesses (if any): (use separate paper if more space is needed)
NAME
TITLE
UNIT
PHONE #
SHIFT
Please provide a detailed description of your grievance. Include dates, locations, and times of
incidents.
(You may attach additional pages or any other relevant documentation, such as a completed MHAS-20
Please number allegations if possible.
incident report if applicable).
Remedy Requested / How can this be resolved?
Signature of Complainant
Date
REV. 7/12/2018
AA GRIEVANCE FORM AA-100
PAGE 2 OF 2

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