Fillable DISCRIMINATION COMPLAINT FORM (EEO) The Office of Diversity (Fulton County Government)

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DISCRIMINATION COMPLAINT FORM (EEO) The Office of Diversity (Fulton County Government)

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DISCRIMINATION COMPLAINT PROCEDURE DESCRIPTION
The Office of Diversity and Civil Rights Compliance (DCRC) is pleased to have an
opportunity to assist you.
In order to assist you properly, the DCRC needs your cooperation in obtaining
information that will allow staff to provide you with the best service possible. The
attached Discrimination Complaint Form is designed to provide the information needed
to get started. The Discrimination Complaint Form must be fully completed.
Please return the completed Discrimination Complaint Form to a DCRC administrative
support member who will forward your paperwork to the EEO Officer. The EEO Officer
will schedule a follow up appointment to review your information with you. The EEO
Officer will talk with you about your concerns and issues so that a detailed
understanding of you case can be developed.
The information you have provided will be review and where appropriate an EEO Officer
will be assigned to contact and work with you to resolve your concerns. The EEO Officer
you worked with initially may/may not be the person who is assigned to work with you to
resolve your concerns.
Please complete the Discrimination Complaint Form and attach any documentation you
may have pertaining to the issues you have expressed. Discrimination Complaint Forms
should be mailed or hand-delivered to The Office of Diversity and Civil Rights
Compliance, 141 Pryor Street, SW, 5th Floor Atlanta, Georgia 30303. If you require
any
help or have any additional questions, you may call the Office of Diversity and Civil
Rights Compliance at 404-612-3735.
Thank you for contacting us. We look forward to working with you.
“Fulton County is an equal opportunity employer encouraging diversity!”
If you need reasonable modifications due to a disability, including communications in an alternate format,
please contact 404-612-7390.
For TDD/TTY or Georgia Relay Service Access, dial 711.
Revised on 1/19/17
Page 1 of 6
DISCRIMINATION COMPLAINT FORM (EEO)
The Office of Diversity a
nd Civil Rights Compliance
141 Pryor Street, SW, 5th Floor
Atlanta, Georgia 30303
Office: 404-612-3735
Revised on 1/25/17 Page 2 of 6
FULTON COUNTY OFFICE OF DIVERSITY AND CVIL RIGHTS COMPLIANCE
1. What is discrimination?
Discrimination is biased or unfair treatment against an employee in the terms, conditions and
privileges of employment because of one’s race, color, religion, sex, pregnancy (including
childbirth, lactation or related medical conditions), sexual orientation, gender identity or
expression, age (40 and over), national origin or ancestry, physical or mental disability, genetic
information (including testing and characteristics), veteran status, uniformed service-member
status, or any other status protected by federal, state or local law.
2. I think I have been discriminated against, but I’m not sure. What do I do?
Employees who feel they have been discriminated against should call the Office of Diversity and
Civil Rights Compliance to schedule an appointment to discuss your complaint. During the intake
process, it will be determined whether or not your complaint has a discriminatory basis.
3. When should I file a complaint?
A complaint of discrimination must be filed with the Office of Diversity and Civil Rights Compliance
within thirty (30) days of the date on which the unfair employment practice took place. Under
certain conditions, a waiver of the filing deadline may be granted. Waivers will be approved or
denied at the time an untimely charge is filed.
4. Do I need to have permission from my supervisor or department head to come to the Office
of Diversity and Civil Rights Compliance and will I have to use leave time?
Employees do not have to have permission to come to the Office of Diversity and Civil Rights
Compliance. However, employees cannot simply walk off of their jobs without giving notice to their
supervisors. Employees also do not have to use leave time to come to the DCRC.
5. Is the Office of Diversity and Civil Rights Compliance the only place I can file a charge of
discrimination?
No. Employees who feel they have been discriminated against may also file with the U. S. Equal
Employment Opportunity Commission (EEOC) located at 100 Alabama Street, S. W., Atlanta,
Georgia, 30303. Employees can file a complaint of discrimination with either the Office of
Diversity and Civil Rights Compliance or the EEOC or both agencies simultaneously.
6. What happens if the unfair treatment I allege is not discrimination?
If it is determined after an intake interview that your complaint is not based on discrimination, you
will be referred to the appropriate resource for the resolution of your complaint. The Office of
Employee/Labor Relations and the Grievance Process are resources for employees to resolve
complaints that do not have a discriminatory basis.
7. Can my supervisor fire, demote or treat me differently because I filed a complaint of
discrimination or participated in an investigation of discrimination?
No. Employers cannot retaliate against employees who file a charge of discrimination or
participate in an investigation of discrimination. Every employee has the right to a fair inquiry if
they feel that they have been a recipient of alleged discrimination.
FREQUENTLY ASKED QUESTIONS AND ANSWERS ABOUT FILING AN
EMPLOYMENT DISCRIMINATION COMPLAINT
?
Revised on 1/25/17 Page 3 of 6
Instructions: Complete this form by providing as much detailed information as
possible. You may attach additional sheets if necessary.
1. NAME (Last, First, Middle) Mr. Ms. Mrs. 2. LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER
3. HOME ADDRESS (No. and Street) Apt # 4. CITY AND STATE
ZIP CODE
5. HOME PHONE + AREA CODE
6. WORK PHONE + AREA CODE
7. PAGER/CELL + AREA CODE
8. E-MAIL ADDRESS 9. RACE 10. GENDER 11. DATE OF HIRE (IF APPLICABLE)
12. DEPARTMENT NAME 13. IMMEDIATE SUPERVISOR 14. SUPERVISOR PHONE + AREA CODE
(IF APPLICABLE) (IF APPLICABLE) (IF APPLICABLE)
15. YOUR WORK LOCATION 16. YOUR POSITION/TITLE
(IF APPLICABLE) (IF APPLICABLE)
17. CURRENT EMPLOYMENT STATUS (Check One):
Classified Full Time Employee Contract Employee Contractor/Sub-Contractor
Grant-Funded Employee Part-Time Employee Participant
Probationary Employee Temporary Employee Applicant
Unclassified Full Time Employee Work Test Employee Other (e.g. Citizen, Client, Patron)
18. Are you currently working with an employee organization/union representative or
attorney?
Yes No If yes, please provide the following information:
Name of Organization/Union:
Name of Representative:
Name of Attorney:
Phone Number:
FULTON COUNTY OFFICE OF DIVERSITY AND CIVIL RIGHTS COMPLIANCE
DISCRIMINATION COMPLAINT FORM
Revised on 1/25/17 Page 4 of 6
19a. Have you ever filed a charge alleging similar facts with any of the following
offices? Check all that apply.
DCRC EEOC Grievance State Agency
CRC Local Agency State Court Federal Court
Other Federal Agency
19b. Provide a brief summary of the allegations of the previously filed
charge/complaint:
20a. INDICATE THE BASIS FOR THE ALLEGED DISCRIMINATION. Check all boxes
that apply:
DISCRIMINATION
AGE (40 AND OVER) COLOR DISABILITY – EMPLOYMENT
GENECTIC INFO GENDER NATIONAL ORIGIN
PREGNANCY RACE RELIGION
RETALIATION GENDER IDENTITY SEXUAL HARASSMENT
UNIFORMED SERVICE-MEMBER STATUS VETERNS STATUS
DISABILITY – PROGRAM ACCESS TITLE VI – CRA
OTHER ______________________________________
20b. WHO IS BEING NAMED AS THE ALLEGED VIOLATOR(S)?
1.
Name Job Title
Department
Phone + Area Code
2.
Name Department Phone + Area Code
3.
Name
Department
Phone + Area Code
Revised on 1/25/17 Page 5 of 6
20c. IDENTIFY THE ISSUE(S) FOR THE ALLEGED DISCRIMINATION. Check all
boxes that apply and provide the date on the line:
ISSUE(S)
DISCHARGE __________________________ DISCIPLINE ____________________
FORCED RESIGNATION ________________ DEMOTION ____________________
FAILURE TO PROMOTE _________________ FAILURE TO HIRE ______________
DENIED REASONBLE INVOLUNTARY
ACCOMODATION ______________________ TRANSFER _____________________
HOSTILE WORK ________________________ WIOA TITLE I ___________________
ENVIRONMENT
DENIED ACCESS TO SERVICES ______________________________________________
OTHER ___________________________________________________________________
20d. Briefly describe your issue, concern or complaint in detail including dates.
Attach any documents or other evidence which you believe will help clarify,
support or provide any useful additional information.
Revised on 1/25/17 Page 6 of 6
20e. WHAT WOULD YOU ACCEPT AS A REASONABLE RESOLUTION TO YOUR
COMPLAINT?
SIGNATURE DATE
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Completed 6 August 2020

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