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Request for Investigation by the

Department of State Civil Service

Please print or type legibly

Name:

Title:

Address:

Email Address:

Home phone:

Cell phone:

Work phone:

Best time to call you:

Do you work for a state agency?

If so, which agency?

Which division or office?

Where is your office or job?

(You do not have to provide the information above, but it will help us in our investigation.)

We investigate violations of the Civil Service Article or Rules, including discrimination, in the state classified service.

Please answer these questions with as much information as you know. You may use separate sheets of paper.

Are you reporting an Article or Rule violation, discrimination, or both?

For discrimination, what is the discrimination based on (race, sex,…)?

For rule violations, what rules were violated?

Who took the action(s) you are reporting? Name:

Title: Agency:

**Please give the same information on a separate sheet of paper if more than one person did the acts you are reporting.

What specific action(s) are you reporting? We need as many details as you know. Please provide dates, times, places,

and anything else you think may help us get to the truth. We especially need to know the names of any witnesses and

descriptions of any official records or documents, which would provide evidence to support your claim. You may use

separate sheets of paper if you need to.

If you are reporting discrimination, you must give specific facts that are detailed enough to verify and to allow the

defendant to prepare a defense. A conclusion of discrimination is not sufficient. The specific facts will vary for each case,

but they may include:

(1) the person or agency that took the action and the date, time, and place of the action

(2) how the person discriminated against was similarly situated to others

(3) the names, job titles, and job locations, of the other people who were similarly situated

(4) how and when those people were treated differently

(5) the events, including dates and circumstances, that led you to believe that the action was based on

discrimination

(6) any other information which may help prove that the action occurred and was based on discrimination

What action do you think we should take if we can prove the action you are reporting?

Please send us copies of anything that may help to prove the actions you are reporting.

Submit to: State Civil Service Compliance and Audit Division – Investigations, P.O. Box 94111, Baton Rouge, LA 70804-9111

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