Fillable DEED Complaint Form - Employment & Economic Development (Minnesota)

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DEED Complaint Form - Employment & Economic Development (Minnesota)

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The DEED Complaint Form - Employment & Economic Development (Minnesota) form is 4 pages long and contains:

  • 1 signature
  • 22 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

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Revised 09/2018
Complaint Form
If you believe you have experienced discrimination, sexual harassment, retaliation for filing a complaint or for
your participation in an investigation, or treated in a way that violates the Respectful Workplace Policy, you are
encouraged to file a complaint. Send completed forms to DEED.ODEO@state.mn.us.
Relevant policy information is listed on the last page of this form.
Complainant (Personal Information about You)
Complainant’s Name:
Preferred Email:
Preferred Phone:
Work Address (including City and Zip):
Job Title:
Division/Agency:
Manager:
Respondent (Person Against Whom You are Filing the Complaint)
Respondent’s Name:
Preferred Email:
Preferred Phone:
Work Address (including City and Zip):
Job Title:
Division/Agency:
Manager:
Information on Witnesses Who You Believe Can Support Your Complaint
Witness Name Witness Job Title Work Location Witness Work Phone
Additional witnesses may be listed on a separate sheet attached to this form.
Union Grievance
Have you filed a union grievance? _____ Yes _____ No
If yes, what union are you a member of? _______________________________________________
If yes, what is the status or outcome of the grievance? ____________________________________
External Complaint
Have you filed this complaint with any other governmental agency (Equal Employment Opportunity
Commission, Minnesota Department of Human Rights, etc.)? _____ Yes _____ No
If yes, what agency?
If yes, what is the status of the complaint?
The Complaint
Date(s) of Complaint
Date harassment/discrimination began or occurred:
Most recent date of harassment/discrimination (if different from above):
Basis of Complaint
Check all that apply:
I experienced unwelcome conduct of a sexual nature. (Sexual Harassment Prohibited Policy*)
I experienced discrimination or discriminatory harassment* based on my (check all that apply):
Race
Color
National Origin
Limited English Proficiency
Religion
Creed
Disability
Marital Status
Familial Status
Age
Sex
Pregnancy
Gender Identity
Gender Expression
Sexual Orientation
Genetic Information
Public Assistance Status
Membership or Activity in a Local
Human Rights Commission
I experienced harassment or disrespectful behavior, but it is not based on any of the
protected characteristics listed above. (Statewide Respectful Workplace Policy*)
I experienced retaliation for filing a complaint or participating in an investigation.
*For more information about the policies under which complaints may be filed, see last page.
Describe, in as much detail as possible, the conduct that you believe violates the Harassment and
Discrimination Prohibited Policy, the Sexual Harassment Prohibited Policy, or the Respectful
Workplace Policy. List dates, locations, names, and titles of people involved. Explain why you
believe the conduct was based on the items checked in the “Basis of Complaint” section above.
Use additional paper if needed and attach to this form. Attach any documents you believe may be
relevant (emails, notes, texts, etc.).
Verification
This complaint is being filed based on my honest belief that I have been subjected to conduct in violation of
the Harassment and Discrimination Prohibited Policy, the Sexual Harassment Prohibited Policy, or the
Respectful Workplace Policy. I hereby certify that the information I have provided in this complaint is true,
correct, and complete to the best of my knowledge.
Complainant’s signature: Date Signed:
Complaint Received by: Date Signed:
click to sign
signature
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Complaint Policy Information
Harassment and Discrimination Prohibited Policy
DEED’s Harassment and Discrimination Prohibited Policy strictly prohibits any form of harassment or
discrimination based on protected class. No one will be denied the opportunity to participate in any DEED
program, activity, or service, or in any employment activity based on race, color, religion, national origin
(including limited English proficiency), sex (including pregnancy, and pregnancy related conditions, gender
identity and expression), age, disability, genetic information, creed, sexual orientation, marital status,
familial status, status with regard to public assistance, or membership in a local human rights commission.
Sexual Harassment Prohibited Policy
DEED’s Sexual Harassment Prohibited Policy strictly prohibits sexual harassment in any form of any
employee or third party that takes place within the workplace or public service environment, or that affects
the workplace or public service environment. These prohibitions extend to any location, activity, or event
associated with DEED or its employees in their capacities as representatives of the State of Minnesota.
Respectful Workplace Policy
The State of Minnesota is committed to providing a positive environment in which all staff, members of the
public and others doing business with the state are treated with professionalism and respect. Issues of
harassing behavior not based on the protected classes listed above are prohibited under the statewide
Respectful Workplace Policy
.
Non-Retaliation Notice
Retaliation against any person who reports conduct under the Harassment and Discrimination Prohibited
Policy, the Sexual Harassment Prohibited Policy, or the Respectful Workplace Policy is strictly prohibited
and will not be tolerated. If you believe that you have been subjected to retaliation, you are encouraged to
report such behavior.
Privacy Notice
DEED is asking you to provide information in this complaint form which includes private and/or confidential
information under the Minnesota Government Data Practices Act. DEED is asking for this
private/confidential information so that it can investigate and respond to allegations of harassment,
discrimination, or disrespectful behavior. You are not legally required to provide this information. However,
if you do not provide sufficient information, DEED may not be able to properly investigate your complaint.
The information you provide will be used by DEED employees whose job assignments reasonably require
access to the information.
Questions
If you have any questions about the complaint process, please contact the Office of Diversity and Equal
Opportunity at 651-259-7684.
This material is available in alternative formats for individuals with disabilities by calling 651-259-7094.
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DEED Complaint Form - Employment & Economic Development (Minnesota)

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Completed 11 September 2020

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