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

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

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The Formal Discrimination/ Sexual Harassment/ Retaliation Complaint Form (NJ Judiciary) form is 2 pages long and contains:

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Revised 09/2020: CN 10493 page 1 of 2
New Jersey Judiciary
EEO Complaint Form: Report of Discrimination, Sexual Harassment, Retaliation
Please type or clearly print all information.
Complainant Information
Prefix
First Name
Middle Name
Home Address
City
State
Zip
Telephone
Email
Complainant Status (check applicable box)
Judicial Employee
(Job Title)
(Vicinage / Division/ AOC)
Volunteer
Job Applicant
Other
(Vicinage)
(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
Religion/Creed
Age
Sex / Gender
Gender Identity or
Expression
Affectional or
Sexual Orientation
Pregnancy or
Breastfeeding
Sexual Harassment
Civil Union Status
Domestic Partnership Status
Marital Status
Veteran Status or Liability for Military Service
Disability/Perceived Disability
Atypical Hereditary Cellular or Blood Trait
Genetic Information
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
Save
Print
Clear
Revised 09/2020: 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 (NJ Division on Civil
Rights) and federal law (Equal Employment Opportunity Commission).
EEO/AA Officer or AOC Investigator’s Name
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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Formal Discrimination Sexual Harassment Retaliation Complaint Form (NJ Judiciary)

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Completed 28 January 2021

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