Fillable Complaint Form Formal Discrimination / Sexual Harassment / (NJ Judiciary)

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Complaint Form Formal Discrimination / Sexual Harassment / (NJ Judiciary)

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Revised 04/2018: CN 10493 page 1 of 2
New Jersey Judiciary
Formal Discrimination / Sexual Harassment / Retaliation
Complaint Form
Please type or clearly print all information.
Date Filed:
Complainant Information
Last Name (include: Sr. / Jr. / III, etc.)
First Name
Middle Name
Home Address
State
Zip
Home Telephone
Work Telephone
Email
Job Title
Vicinage / Division / AOC
Complainant Status (check applicable box)
Judicial Employee Volunteer Other
If you check “other” specify whether:
Job Applicant
Probationer
Vendor
Other (Litigant, Witness, etc.)
(specify)
Name and Title of Person(s) You Believe Discriminated Against You
Name
Job Title
Vicinage / Division / AOC
Name
Job Title
Vicinage / Division / AOC
Name
Job Title
Vicinage / Division / AOC
Basis of Complaint (check applicable box or boxes)
Race Color National Origin / Nationality Ancestry Affectional or Sexual Orientation
Sex / Gender Pregnancy or
Breastfeeding
Gender Identity
or Expression
Disability /
Perceived Disability
Atypical Heredity Cellular
or Blood Trait
Use of Genetic Information, Including Refusal to
Submit to or Provide Results of Genetic Test
Religion / Creed Veteran Status or Liability
for Military Service
Marital Status
Civil Union Status Domestic Partnership Status Age Sexual Harassment Retaliation
Description of Complaint: List each incident separately and describe in detail the incident(s) and time and place
of occurrence.
NOTE: A copy of this form will be provided to the person(s) against whom you are filing a complaint. Therefore
you should not identify witnesses or background evidence on this form. You will be asked to submit that material
separately to the investigator who will investigate your complaint.
Description of Incident
Date of Incident
Was Incident Reported to Anyone?
If Yes, Who?
Date Reported
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Revised 04/2018: CN 10493 page 2 of 2
Description of Incident
Date of Incident
Was Incident Reported to Anyone?
If Yes, Who?
Date Reported
Description of Incident
Date of Incident
Was Incident Reported to Anyone?
If Yes, Who?
Date Reported
Description of Incident
Date of Incident
Was Incident Reported to Anyone?
If Yes, Who?
Date Reported
Description of Incident
Date of Incident
Was Incident Reported to Anyone?
If Yes, Who?
Date Reported
Remedy Sought (Explanation)
Additional pages may be attached
NOTE: The Complainant has a right to use the external procedures available under state law (Division on Civil
Rights) and federal law (Equal Employment Opportunity Commission). Information regarding external procedures
is contained in the Policy Statement and on posters located in the Human Resources Office.
Local EEO/AA Officer / AOC Investigator Signature
Date
Complainant’s Signature
Date
Please submit form to the local EEO/AA Officer or to the
Chief Judiciary EEO/AA Officer in the AOC.
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Complaint Form Formal Discrimination Sexual Harassment (NJ Judiciary)

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Completed 21 July 2020

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