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Florida Department of TRANSPORTATION

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

DISCRIMINATION/SEXUAL HARASSMENT COMPLAINT FORM

275-610-01
EQUAL OPPORTUNITY
11/11
Any applicant or employee may file a discrimination or sexual harassment complaint.
Complainant is (check one):

COMPLAINANT INFORMATION

(*) indicates a required field.








Format: (000) 000-0000

Format: (000) 000-0000

PERSON/LOCATION NAMED IN COMPLAINT









Address of unit or office









BASIS OF ALLEGED DISCRIMINATION (Reason for discrimination)

Check appropriate box(es)

TERMS/CONDITIONS OF ALLEGED DISCRIMINATION (Harm Alleged)

Check appropriate box(es)


EXPLANATION