Weber County Human Resources
EEO Complaint Form
Date:
Name:
Division:
Job Title: Job Location:
Immediate Supervisor's Name:
Contact Information:
Work Phone: Cell Phone: E-mail Address:
Nature of complaint (in complainant's words):
Are there any witnesses to the alleged incident(s)? If yes, please identify them below.
Name Job Title Division/Work Location Phone Number
Please check one of the boxes below regarding your complaint:
I want to talk with the EEO staff before deciding whether to file a charge. I understand that by checking this box I have
not filed a charge. I also understand that I could lose my rights if I don't file a charge within 30 working days from the
date I had knowledge of the discrimination, harassment or retaliation.
I want to file a charge of Discrimination or Retaliation based
on the following protected category or activity (reference
highlighted section above).
By signing below I understand that I am entering into the EEO Complaint Process as outlined in policy.
Signature Date
Human Resources Policy:
Visit the the Weber County Human Resources website for policies and procedures covered by the HR Policy 3-100
I understand that the EEO complaint process is intended to address allegations of discrimination or harassment
on race, color, national origin, religion, sex (including sexual harassment and sexual orientation), age,
pregnancy, genetic information, veteran's/military status, marital status and gender identity. The process is
intended to address allegations of retaliation for participating in a protected activity (e.g. filing a
appearing as a witness, or requesting ADA or FMLA).
Human Resources
