Employment Discrimination Complaint Form
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3STATE OF ALASKA
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EMPLOYMENT DISCRIMINATION COMPLAINT
I. GENERAL INFORMATION
Name: _____________________________ Social Security Number:________________
Mailing Address:___________________________________________________________
Home Phone Number: ____________________ Contact Phone:_____________________
II. EMPLOYMENT INFORMATION (Current or former state employee only)
Date of Hire: __________________ Present Job Title:________________________
Department: __________________________ Division: __________________________
Phone: ___________
Work Address:______________________________________________________________
Supervisor's Name: ______________________________ Title: ___________________
III. APPLICANT INFORMATION (Applicant for state employment only)
Job Class (Title) you applied for: ________________________________________
If you responded to a letter from a department which invited you to apply
for a vacancy, please provide the following information:
Department:_____________________ Division:_________________________________
Date: ____ Contact Person:_______________Were you interviewed?Yes ___ No___
IV. TYPE OF DISCRIMINATION (Check applicable)
___
Race
___
Change in Marital Status
___
Pregnancy
___
Sex
___
Religion
___
Veteran Status
___
Sexual Harrassment ___
Color
___
Age **
___
Disability
___
Retaliation *
___
National Origin
___
Marital Status
___
Parenthood
* AS 44.19.456 RETALIATION PROHIBITED
(a) Any agency, officer, or state employee may not directly or indirectly
refuse to hire, transfer, or promote, or dismiss,demote, suspend, lay
off, or otherwise discipline a person for filing a complaint with the
office for a failure to comply with affirmative action or equal employment
opportunity or for assisting the office in an investigation of a complaint.
** The Age Discrimination in Employment Act of 1967 ADEA protects individuals
who are 40 years of age or older from discrimination based on age.
V. DATE OF MOST RECENT DISCRIMINATORY ACT OR PRACTICE
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