State of New Jersey Civil Service Commission
Offi ce of Equal Employment Opportunity and Affi rmative Action
Discrimination Complaint Processing Form
For detailed information on the complaint process, see the State of New Jersey Model Procedures for Processing
Internal Complaints Alleging Discrimination in the Workplace (Model Procedures) on Page 2 of this form.
INSTRUCTIONS: This complaint form can be completed by a complainant or with the assistance of the Equal
Employment Opportunity/Affi rmative Action Offi cer or the alternate designee for the State department, agency,
commission, or State college/university where you work or applied for employment.
1. Name: 2. Name of State Dept., Agency, Commission or College: 3. Telephone (Work):
4. Job Title: 5. Division / Of ce / Facility: 6. Telephone (Home):
7. Home Address: 8a. Full name, title, and telephone number of person(s) you believe discriminated against you:
8. Date(s) of discriminatory action(s):
8c. Complainant’s Status (Check applicable box):
Employee Job Applicant Vendor/Contractor Other (Please specify)
9. Basis of Discrimination:
10a. Explain why you feel you have been discriminated against: CHECK IF ADDITIONAL SHEETS ARE ATTACHED
10b. Were the actions or behavior you are complaining about directed at, or said to, you and/or another party (third party harassment)?
10c. Was the incident reported to anyone? YES NO If yes, who and when?
10d. What remedy or resolution are you seeking?
10e. If appropriate, as determined by the EEO Of cer, are you willing to attempt to resolve your complaint through mediation or another alternative dispute resolution (ADR) process?
YES NO
10f. Complainant’s Signature: Date:
11. Have you led a discrimination complaint with the
• N.J. Division on Civil Rights? YES NO
• U.S. Equal Employment Opportunity Commission? YES NO
12. Have you led a grievance on the
issues / personnel actions described?
YES NO
13. Completion of this part is voluntary. The information is to be used only for State and Federal record keeping and reporting requirements:
SEX: Male Female Non-Binary
RACE: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Paci c Islander White
ETHNICITY: Hispanic or Latino Not Hispanic or Latino
Note: In addition to ling an internal complaint, a complainant has a right to use external complaint ling procedures available under State law (with the NJ Division on Civil Rights)
and federal law (with the US Equal Employment Opportunity Commission). Detailed information is contained in the Model Procedures found on Page 2 of this form.
DO NOT WRITE BELOW THIS LINE
EEO/AA Of cer
Signature: Date Received:
Age
Affectional/Sexual Orientation
Ancestry
Atypical Hereditary Cellular or Blood Trait
Color
Creed
Disability
Domestic Partnership Status
Familial Status
Gender Identity or Expression
Genetic Information (including refusal to submit to
or provide results of a genetic test)
Liability for Military Service
Marital /Civil Union Status
Nationality
National Origin
Pregnancy
Race
Religion
Sex/Gender
Sexual Harassment
Retaliation (for having led a discrimination
complaint, participating in a complaint investigation,
or for opposing a discriminatory practice)
P.O. Box 315
Trenton, NJ 08625-0315
609-984-1096
New Jersey Civil Service Commission
Division of EEO/AA
DPF481
Revised 6.21.19
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NEW JERSEY STATE
MODEL PROCEDURES FOR INTERNAL COMPLAINTS ALLEGING
DISCRIMINATION IN THE WORKPLACE
Each State department, commission, State college or university, agency and authority (hereafter
referred to in this section as “State agency”) is responsible for implementing this model procedure,
completing it to refl ect the structure of the organization,and ling a copy of the completed procedure
with the Civil Service Commission, Division of EEO/AA.
1. All employees and applicants for employment have the right and are encouraged to
immediately report suspected violations of the State Policy Prohibiting Discrimination in the
Workplace, N.J.A.C. 4A:7-3.1.
2. Complaints of prohibited discrimination/harassment can be reported to either (Name of
Offi cer), the EEO/AA Offi cer, or to any supervisory employee of the State agency. Complaints
may also be reported to (Authorized Designee).
3. Every eff ort should be made to report complaints promptly. Delays in reporting may not only
hinder a proper investigation, but may also unnecessarily subject the victim to continued
prohibited conduct.
4. Supervisory employees shall immediately report all alleged violations of the State Policy
Prohibiting Discrimination in the Workplace to (Name of Offi cer), EEO/AA Offi cer. Such
a report shall include both alleged violations reported to a supervisor, and those alleged
violations directly observed by the supervisor
.
5. If reporting a complaint to any of the persons set forth in paragraphs 2 through 4 above
presents a confl ict of interest, the complaint may be fi led directly with the Division of EEO/ AA,
P.O. Box 315,Trenton, NJ 08625. An example of such a confl ict would be where the individual
against whom the complaint is made is involved in the intake, investigative or decision making
process.
6. In order to facilitate a prompt, thorough and impartial investigation, all complainants are
encouraged to submit a Division of EEO/AA Discrimination Complaint Processing Form.
An investigation may be conducted whether or not the form is completed.
7. Each State agency shall maintain a written record of the discrimination harassment complaints
received. Written records shall be maintained as confi dential records to the extent practicable
and appropriate. A copy of all complaints (regardless of the format in which submitted) must
be submitted to the Civil Service Commission, Division of EEO/AA, by the State agency’s
EEO/AA Offi cer, along with a copy of the acknowledgement letter(s) sent to the person(s) who
led the complaint and, if applicable, the complaint notifi cation letter sent to the person(s)
against whom the complaint has been led. If a written complaint has not been led, the
EEO/AA Offi cer must submit to the Division of EEO/AA a brief summary of the allegations
that have been made. Copies of complaints fl ied with the New Jersey Division on Civil Rights,
the U.S. Equal Employment Opportunity Commission, or in court also must be submitted to
the Division of EEO/AA.
8. During the initial intake of a complaint, the EEO/AA Offi cer or authorized designee will
obtain information regarding the complaint,and determine if interim corrective measures are
necessary to prevent continued violations of the State Policy Prohibiting Discrimination in
the Workplace.
9. At the EEO/AA Offi cer’s discretion, a prompt, thorough, and impartial investigation into the
alleged harassment or discrimination will take place.
10. An investigatory report will be prepared by the EEO/AA Offi cer or his or her designee when
the investigation is completed The report will include,at a minimum:
a. A summary of the complaint;
b. A summary of the parties’ positions;
c. A summary of the facts developed through the investigation; and
d. An analysis of the allegations and the facts.
The investigatory report will be submitted to (State agency head or designee) who will
issue a fi nal letter of determination to the parties.
11. The (State agency head or designee) will review the investigatory report issued by the EEO/
AA Offi cer or authorized designee, and make a determination as to whether the allegation
of a violation of the State Policy Prohibiting Discrimination in the Workplace has been
substantiated. If a violation has occurred, the (State agency head or designee) will determine
the appropriate corrective measures necessary to immediately remedy the violation.
12. The (State agency head or designee) will issue a nal letter of determination to both the
complainant(s) and the person against whom the complaint was fl ied, setting forth the results
of the investigation and the right of appeal to the Civil Service Commission, as set forth in
Paragraphs 13 and 14, below. To the extent possible, the privacy of all parties involved in the
process shall be maintained in the nal letter of determination. The Civil Service Commission’s
Division of EEO/AA shall be furnished with a copy of the fi nal letter of determination.
a. The letter shall include, at a minimum:
1. A brief summary of the parties’ positions;
2. A brief summary of the facts developed during the investigation; and
3. An explanation of the determination, which shall include whether:
i. The allegations were either substantiated or not substantiated, and
ii. A violation of the State Policy Prohibiting Discrimination in the Workplace
did or did not occur.
b. The investigation of a complaint shall be completed and a fi nal letter of determination
shall be issued no later than 120 days after the initial intake of the complaint referred
to in Paragraph 8, above, is completed.
c.
The time for completion of the investigation and issuance of the fi nal letter of determination
may be extended by the State agency head for up to 60 additional days in cases involving
exceptional circumstances. The State agency head shall provide the Division of EEO/
AA and all parties with written notice of any extension and shall include in the notice an
explanation of the exceptional circumstances supporting the extension.
13. A complainant who is in the career, unclassifi ed or senior executive service, or who is an
applicant for employment, who disagrees with the determination of the (State agency head
or designee), may submit a written appeal to the, New Jersey Civil Service Commission
(“NJCSC”), Division of Merit System Practices and Labor Relations, Written Record Appeals
Unit, P 0 Box 312,Trenton, NJ 08625-0312, postmarked or delivered within 20 days of the
receipt of the determination from the (State agency head or designee). The appeal shall be
in writing and include all materials presented by the complainant at the State agency level, the
nal letter of determination, the reason for the appeal and the specifi c relief requested. Please
be advised that there is a $20 fee for appeals. Please include a check or money order along
with the appeal, payable to NJCSC. Persons receiving public assistance and those qualifying
for NJCSC Veterans Preference are exempt from this fee, to the Civil Service Commission,
PO Box 312, Trenton, N.J. 08625.
a. Employees ling appeals which raise issues for which there is another specifi c appeal
procedure must utilize those procedures. The Civil Service Commission Chair may require
any appeal, which raises issues of alleged discrimination and other issues, such as
examination appeals, to be processed using the procedures set forth in this section or a
combination of procedures as the Chair deems appropriate. See N.J.A.C. 4A2-1.7.
b. The Civil Service Commission shall decide the appeal on a review of the written record or
such other proceeding as it deems appropriate. See N.J.A.C. 4A:2-1.1(d)
c. The appellant shall have the burden of proof in all discrimination appeals brought before
the Civil Service Commission.
14. In a case where a violation has been substantiated, and no disciplinary action recommended,
the party(ies) against whom the complaint was fi led may appeal the determination to
the Civil Service Commission at the address indicated in Paragraph 13 above, within 20
days of receipt of the nal letter of determination by the State agency head or designee.
a. The burden of proof shall be on the appellant.
b. The appeal shall be in writing and include the fi nal letter of determination, the reason for
the appeal, and the specifi c relief requested.
c. If disciplinary action has been recommended in the fi nal letter of determination, the
party(ies) charged may appeal using the procedures set forth in N.J.A.C. 4A2-2 and 3.
15. The Division of EEO/AA shall be placed on notice of, and given the opportunity to submit
comments on, appeals led with the Civil Service Commission of decisions on discrimination
complaints, regardless of whether or not the complaint was initially led directly with the
Division of EEO/AA.
16. Any employee or applicant for employment can le a complaint directly with external
agencies that investigate discrimination/harassment charges in addition to utilizing this
internal procedure. The time frames for ling complaints with external agencies indicated
below are provided for informational purposes only. An individual should contact the specifi c
agency to obtain exact time frames for ling a complaint The deadlines run from the date of
the last incident of alleged discrimination/harassment, not from the date that the fi nal letter of
determination is issued by the State agency head or designee.
Employees may fi le complaints with the following external agencies:
Division on Civil Rights
N.J. Department of Law & Public Safety
(Within 180 days for violation of the discriminatory act)
United States Equal Employment Opportunity
Commission (EEOC)
(Within 300 days of the discriminatory act)
National Call Center 1-800-669-4000
Central Regional Offi ce
140 East Front Street, 6th Floor
P.O. Box 090
Trenton NJ 08625-0090
(609) 292-4605
Northern Regional Offi ce
31 Clinton Street, 3rd fl oor
P.O. Box 46001
Newark, NJ 07102
(973) 648-2700
South Shore Regional Offi ce
1325 Boardwalk,1st Floor
Tennessee Avenue and Boardwalk
Atlantic City, NJ 08401
(609) 441-3100
Southern Regional Offi ce
5 Executive Campus, Suite 107
Cherry Hill, NJ 08034
(856) 486-4080
*Newark Area Offi ce
2 Gateway Center, 17
th
Floor
Newark, NJ 07102(973) 645-4684
**Philadelphia District Offi ce
801 Market Street, Suite 1300
Philadelphia, PA 19107-3127
(215) 440-2600
Issued: December 16, 1999
Revised: June 3, 2005
Revised: August 20, 2007
Revised: October 15, 2009
Revised: March 24, 2010
Revised: February 8, 2011
Revised: November 15, 2011
Revised: March 22, 2016
See N.J.A.C. 4A:7-3.2
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