Discrimination Complaint Form - Illinois Department Of Commerce And Economic Opportunity Page 2

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Date complaint was presented to immediate supervisor? (if applicable) ________________________
Was it Oral or Written? ____________________________
Signature/date of immediate supervisor acknowledging discussion of complaint: (if applicable)
_________________________
Date:_______________________
Have you attempted to resolve this complaint? (please circle)
Yes
No
Explain briefly and clearly what happened and how you were discriminated against. State the facts as alleged,
including pertinent dates, constituting the alleged violation. Indicate who (names and titles) was involved and
be sure to include how other person(s), if known, were treated differently from you. Attach any written
documentation/material pertaining to the case. Please state the provisions of WIOA, including regulations,
grants, contracts, or other agreements believed to be violated.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Attach additional sheets, if necessary. Each sheet/attachment should identify complainant by name, be signed
by complainant and dated.
Remedy sought by complainant:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have an attorney? (please circle)
Yes
No
Attorney’s Name and Address:
__________________________________________
Date:___________________
Signature of Complainant/Authorized Representative
___________________________________________
Date:____________________
Signature of EO Officer

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