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NEW JERSEY DEPARTMENT OF CORRECTIONS EQUAL EMPLOYMENT DIVISION (New Jersey Department of Corrections)

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NEW JERSEY DEPARTMENT OF CORRECTIONS
EQUAL EMPLOYMENT DIVISION (EED) COMPLAINT
OF DISCRIMINATION, HARASSMENT AND/OR RETALIATION
To file an internal complaint of employment discrimination with the New Jersey Department of
Corrections, you must complete this form and return it to the EED office or to the Associate/
Assistant Superintendent Liaison (ASL) at your facility within thirty (30) days of the last act of
alleged discrimination, harassment or retaliation.
**ALL SECTIONS OF THE COMPLAINT FORM MUST BE COMPLETED.**
First Name
Date of Complaint
Job Title
Facility or Operational Unit where Employed:
Address
City
State Zip Code
Home Address:
Race
Age
Work number
Home Number
Alternate Number
Date of Incident(s)
Other Number(s) Where You Can Be Reached:
Last Name
Middle Initial
Sex
Male
Female
Other Names Used:
First Name
Job Title
Location:
Last Name
Middle Initial
Accused's Information
Basis of Discrimination/Harassment/Retaliation (check as many as are applicable):
Affectional/Sexual Orientation
Age
Ancestry
Atypical Hereditary Cellular or Blood Trait
Color
Creed
Disability
Familial Status
Liability for Military Service
Marital/Civil Union Status
National Origin/Nationality
Race
Retaliation (for having filed or participated in a previous discrimination complaint)
Sex/Gender (including pregnancy)
Sexual Harassment
Religion
Have you filed a complaint with any of the following agencies? (Check as many as are applicable)
Division on Civil Rights (NJDCR), New Jersey Department of Law and Public Safety
United States Equal Employment Opportunity Commission (EEOC)
If you checked any of the above agencies, please indicate when you filed the complaint
and describe the status of the complaint:
Date/Time Field
Domestic Partnership Status
Genetic Information (including refusal to submit to or provide results of a genetic test)
Gender Identity or Expression
Pregnancy
Have you filed a union grievance related to the facts stated in this complaint?
Yes No
If you answered yes, please indicate when you filed the grievance and describe the status of the grievance. Please attach a copy of the
grievance form:
Upon receipt of your complaint, the supervisor of the EED Office will determine whether your complaint will be investigated by an EED
investigator or by the Associate/Assistant Superintendent Liaison (ASL) at your facility. If you have a reason(s) for not wanting the ASL at
your facility to investigate your complaint, please explain the reason(s):
Please describe the nature of your complaint:
**You are required to provide a narrative. In addition to the narrative, you
may attach other documents relevant to the facts stated in this narrative.**
Please provide the names of individuals who may be witnesses to the alleged discrimination, harassment or retaliation, or who
may have relevant information about your complaint:
BE SURE TO KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Signature
Date
Signature of Person Receiving Complaint:
Name and Title of Person Receiving Complaint:
Date Received
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NEW JERSEY DEPARTMENT OF CORRECTIONS EQUAL EMPLOYMENT DIVISION (New Jersey Department of Corrections)

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Completed 21 July 2020

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