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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

(Please briefly describe with detail the circumstances that cause you to believe you have been discriminated against, harassed or sexually harassed, including dates, please, persons involved and witnesses)
This field contains a maximum character limit of 8,000. If your information exceeds this amount, or you have additional information to attach, please submit via eeocomplaints@dot.state.fl.us