Form GCC-102A "Discrimination Complaint Form" - North Carolina

What Is Form GCC-102A?

This is a legal form that was released by the North Carolina Department of Public Safety - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 7, 2019;
  • The latest edition provided by the North Carolina Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form GCC-102A by clicking the link below or browse more documents and templates provided by the North Carolina Department of Public Safety.

ADVERTISEMENT
ADVERTISEMENT

Download Form GCC-102A "Discrimination Complaint Form" - North Carolina

Download PDF

Fill PDF online

Rate (4.3 / 5) 16 votes
Governor’s Crime Commission
1201 Front Street
Raleigh, NC 27609
Phone: (919) 733-4564 Fax: 919-733-4625
DISCRIMINATION COMPLAINT FORM
The purpose of this form is to assist you in filing a complaint of discrimination with the Governor’s
Crime Commission. The time you take to fill out this form is appreciated, as the Governor’s Crime
Commission needs to know if and when unlawful discrimination is alleged against itself or one of its
recipients or subrecipients.
The Governor’s Crime Commission may use this form in investigating allegations of discrimination,
though action by the Governor’s Crime Commission is not a substitute for legal action or other
remedies that may be available to you. Please be aware that time frames for filing a formal
discrimination complaint or civil action may apply and that retention of legal counsel may be
necessary to safeguard your civil rights. The Governor’s Crime Commission does not give legal advice
nor does it supply legal counsel. Please also know that antidiscrimination laws may contain non-
retaliation provisions that are designed to protect against action taken against persons who file or
participate in claims of unlawful discrimination.
You are not required to use this form, and a letter containing the same information is sufficient.
However, the information requested in the items marked with a star (*) must be provided, regardless
of whether or not this particular form is used.
1.* Write your name and address:
Name: _______________________________________________________
Address: _______________________________________________________
_____________________________ Zip ____________
Telephone No: Home: (_____)_______________ Work: (_____)_______________
2.* Person(s) discriminated against, if different from above:
Name: _______________________________________________________
Address: ______________________________ Zip ___________
Telephone: Home: (_____)_______________ Work: (_____)_______________
Please explain your relationship to this person(s).
3.* Agency and department or program that discriminated:
Name: ________________________________________________________
Any individual if known: _____________________________________________
Address: _______________________________________________________
_____________________________ Zip ___________
Telephone No: (____)_______________
Rev 8/7/19
Page 1 of 6
GCC - 102A
Governor’s Crime Commission
1201 Front Street
Raleigh, NC 27609
Phone: (919) 733-4564 Fax: 919-733-4625
DISCRIMINATION COMPLAINT FORM
The purpose of this form is to assist you in filing a complaint of discrimination with the Governor’s
Crime Commission. The time you take to fill out this form is appreciated, as the Governor’s Crime
Commission needs to know if and when unlawful discrimination is alleged against itself or one of its
recipients or subrecipients.
The Governor’s Crime Commission may use this form in investigating allegations of discrimination,
though action by the Governor’s Crime Commission is not a substitute for legal action or other
remedies that may be available to you. Please be aware that time frames for filing a formal
discrimination complaint or civil action may apply and that retention of legal counsel may be
necessary to safeguard your civil rights. The Governor’s Crime Commission does not give legal advice
nor does it supply legal counsel. Please also know that antidiscrimination laws may contain non-
retaliation provisions that are designed to protect against action taken against persons who file or
participate in claims of unlawful discrimination.
You are not required to use this form, and a letter containing the same information is sufficient.
However, the information requested in the items marked with a star (*) must be provided, regardless
of whether or not this particular form is used.
1.* Write your name and address:
Name: _______________________________________________________
Address: _______________________________________________________
_____________________________ Zip ____________
Telephone No: Home: (_____)_______________ Work: (_____)_______________
2.* Person(s) discriminated against, if different from above:
Name: _______________________________________________________
Address: ______________________________ Zip ___________
Telephone: Home: (_____)_______________ Work: (_____)_______________
Please explain your relationship to this person(s).
3.* Agency and department or program that discriminated:
Name: ________________________________________________________
Any individual if known: _____________________________________________
Address: _______________________________________________________
_____________________________ Zip ___________
Telephone No: (____)_______________
Rev 8/7/19
Page 1 of 6
GCC - 102A
DISCRIMINATION COMPLAINT FORM - CONTINUED
4A.* Non-employment: Does your complaint concern discrimination in the delivery of
services and/or other discriminatory actions by the department or agency in its treatment
of you or others? If so, please indicate below the base(s) on which you believe these
discriminatory actions were taken:
____ Race/Ethnicity: ____________________________
____ National origin: ____________________________
____ Sex: _____________________________________
____ Religion: _________________________________
____ Age: ____________________________________
____ Disability: ________________________________
____ Other: ___________________________________
4B.* Employment: Does your complaint concern discrimination in employment by the
department or agency? If so, please indicate below the base(s) on which you believe these
discriminatory actions were taken.
____ Race/Ethnicity: ______________________________
____ National origin: ____________________________
____ Sex: _____________________________________
____ Religion: _________________________________
____ Age: _____________________________________
____ Disability: ________________________________
____ Other: ___________________________________
5. What is the most convenient time and place for us to contact you about this complaint?
____________________________________________
6. If we will not be able to reach you directly, please give us the name and phone number of
a person who can tell us how to reach you and/or provide information about your
complaint:
Name: ____________________________________________
Telephone No: (_____)_______________
7. If you have an attorney representing you concerning the matters raised in this complaint,
please provide the following information about that attorney:
Name: ____________________________________________
Address: _____________________________________________
Rev 8/7/19
Page 2 of 6
GCC - 102A
DISCRIMINATION COMPLAINT FORM - CONTINUED
_____________________________ Zip ____________
Telephone No: (_____)_______________
8.* To the best of your recollection, on what date(s) did the alleged discrimination take
place?
Earliest date of discrimination: _________________
Most recent date of discrimination: _________________
9.* Please explain as clearly as possible what happened, why you believe it happened, and
how you were discriminated against. Indicate who was involved. Be sure to include how
other persons were treated differently from you. (Please use additional sheets if necessary
and attach a copy of written materials pertaining to your case.)
10. The anti-discrimination laws we monitor for prohibit recipients of Department of Justice
funds from intimidating or retaliating against anyone because he or she has either taken
action or participated in action to secure rights protected by these laws. If you believe that
you have been retaliated against (separate from the discrimination alleged in #9), please
explain the circumstances below. Be sure to explain what actions you took which you
believe were the basis for the alleged retaliation.
Rev 8/7/19
Page 3 of 6
GCC - 102A
DISCRIMINATION COMPLAINT FORM - CONTINUED
11. Please list below any persons (witnesses, fellow employees, supervisors, or others), if
known, whom we may contact for additional information to support or clarify your
complaint.
Name
Address
Area Code/Telephone
12. Do you have any other information that you think is relevant to our investigation of your
allegations?
13. What remedy are you seeking for the alleged discrimination?
14. Have you (or the person discriminated against) filed the same or any other complaints
with other offices (including the Equal Employment Opportunity Commission or the Civil
Rights Division of the North Carolina Office of Administrative Hearings)?
Yes ____ No ____
If so, do you remember the Complaint Number?
______________________________________
Against what agency and department or program was it filed?
______________________________________________
Address: ____________________________________________
________________________ Zip __________________
Telephone No: (____)_______________
Date of Filing: ____________ Other Office: ______________________
Briefly, what was the complaint about?
What was the result?
Rev 8/7/19
Page 4 of 6
GCC - 102A
DISCRIMINATION COMPLAINT FORM - CONTINUED
15. Have you filed or do you intend to file a charge or complaint concerning the matters
raised in this complaint with any of the following?
_____ U.S. Equal Employment Opportunity Commission
_____ Federal or State Court
_____ Your State or local Human Relations/Rights Commission
_____ Grievance or complaint office
16. If you have already filed a charge or complaint with an agency indicated in #15, above,
please provide the following information (attach additional pages if necessary):
Agency: ____________________________________________
Date filed: ___________________________________
Case or Docket Number: ________________________
Date of Trial/Hearing: __________________________
Location of Agency/Court: ___________________________________________
Name of Investigator: _____________________________________________
Status of Case: _____________________________________________
Comments:
17. While it is not necessary for you to know about aid that the agency or institution you
are filing against receives from the Federal government, if you know of any
Department of Justice funds or assistance received by the program or department in which
the alleged discrimination occurred, please provide that information below.
18. How did you learn that you could file this complaint? Please advise so that the
Governor’s Crime Commission can better improve its strategy for responding to allegations
of unlawful discrimination:
19.* We cannot proceed with a complaint if it has not been signed. Please sign and date
below:
________________________________________________________
(Signature)
(Date)
Please feel free to add additional sheets to explain the present situation to us.
We would like your consent to disclose your name and personal information that you or others share
with us in the event that such disclosure becomes necessary in the course of an investigation. Thus,
we will need a signed Consent Form from you (if you are filing this complaint for a person whom you
allege has been discriminated against, we will in most instances need a signed Consent Form from
Rev 8/7/19
Page 5 of 6
GCC - 102A