"Equal Employment Opportunity Discrimination Complaint Form" - Florida

Equal Employment Opportunity Discrimination Complaint Form is a legal document that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida.

Form Details:

  • Released on February 1, 2018;
  • The latest edition currently provided by the Florida Department of Juvenile Justice;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download "Equal Employment Opportunity Discrimination Complaint Form" - Florida

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DEPARTMENT OF JUVENILE JUSTICE
Equal Employment Opportunity
Discrimination Complaint Form
DJJ No.:
(Equal Opportunity Officer Only)
Date:
(MM/DD/YYYY)
Employee:
Applicant for Employment:
A. Complainant Information:
Full Name:
Employee ID# (if applicable):
D.O.B.:
(MM/DD/YYYY)
Work Address:
City:
State:
Zip Code:
Telephone (Home):
Work:
Cell:
B. Information of Person Discriminating Against You:
Name:
Program/Region/Circuit:
Work Address:
City:
State:
Zip Code:
C. Check Cause or Basis of Discrimination
(Check all that apply)
Race
Color
Sex-Female
Sex-Male
Disability
Religion
Age
National Origin
Marital Status
Retaliation
Genetic Information
Sexual Harassment
Other
:
(please explain)
D. Give date most recent or continuing discrimination took place:
(MM/DD/YYYY)
Rev. February 2018
Page 1 of 2
DEPARTMENT OF JUVENILE JUSTICE
Equal Employment Opportunity
Discrimination Complaint Form
DJJ No.:
(Equal Opportunity Officer Only)
Date:
(MM/DD/YYYY)
Employee:
Applicant for Employment:
A. Complainant Information:
Full Name:
Employee ID# (if applicable):
D.O.B.:
(MM/DD/YYYY)
Work Address:
City:
State:
Zip Code:
Telephone (Home):
Work:
Cell:
B. Information of Person Discriminating Against You:
Name:
Program/Region/Circuit:
Work Address:
City:
State:
Zip Code:
C. Check Cause or Basis of Discrimination
(Check all that apply)
Race
Color
Sex-Female
Sex-Male
Disability
Religion
Age
National Origin
Marital Status
Retaliation
Genetic Information
Sexual Harassment
Other
:
(please explain)
D. Give date most recent or continuing discrimination took place:
(MM/DD/YYYY)
Rev. February 2018
Page 1 of 2
Page 2 of 2
E. Give Full Details of Complaint:
(Use additional sheet if necessary)
REASON FOR ADVERSE ACTION:
I.
(State reason given for action taken and Name/Title of persons involved.)
DISCRIMINATION STATEMENT:
II.
(Provide facts, details, dates & comparative statements, i.e., how others
of a different race or sex, etc., were treated differently or more favorably.)
PERSONAL HARM:
III.
(State what harm occurred to you, e.g., Demotion, Discharge, Not Hired, Etc.)
I declare that the foregoing is true and correct:
SIGNATURE OF COMPLAINANT:
DATE:
Applicants and Employees who believe they have been discriminated against may file a complaint with the Bureau of Human
Resources, Equal Employment Opportunity Officer, at 2737 Centerview Drive, Knight Building, Suite 1400, Tallahassee, FL
32399, by telephone at (850) 717-2654 or by email at
HREEOOfficer@djj.state.fl.us
within 365 days of the alleged discriminatory
action. Complaints may also be filed with the Florida Commission on Human Relations (FCHR), 2009 Apalachee Parkway, Suite 200,
Tallahassee, FL 32301-4857, (850) 488-7082; Fax: (850) 488-5291 or the Equal Employment Opportunity Commission (EEOC), Miami
Tower, 100 SE 2nd Street, Suite 1500, Miami, Florida 33131, (800) 669-4000; Fax: (305) 808-1855. For more information on how to
file a complaint please call (850) 717-2654 or send e-mail to HREEOOfficer@djj.state.fl.us.
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