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.

HELP: If you need assistance in order to complete the form, please contact the Equal Opportunity Office at 850.414.4747.

Complainant is (check one):

COMPLAINANT INFORMATION

(*) indicates a required field.

First Name *

Last Name *

District

Work Unit/Office

Primary Phone *
Format: (000) 000-0000

Secondary Phone
Format: (000) 000-0000

Email Address *

PERSON/LOCATION NAMED IN COMPLAINT

First Name

Last Name

Title (if known)

Work Unit/Office

Address of unit or office

Street

City

State

Zip

BASIS OF ALLEGED DISCRIMINATION (Reason for discrimination)

Check appropriate box(es)

TERMS/CONDITIONS OF ALLEGED DISCRIMINATION (Harm Alleged)

Check appropriate box(es)

EXPLANATION

Date of the most recent incident of discrimination or sexual harassment.

(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

I affirm that the information contained in this complaint is true to the best of my knowledge and verify by submitting that I have been informed that my filing a complaint with the Department does not preclude my filing a complaint on the same matter with the Florida Commission On Human Relations (FCHR) or the Equal Employment Opportunity Commission (EEOC). I understand that I have the right to file a complaint with the FCHR within 365 days of the incident in question, or with the EEOC within 300 days of the alleged discriminatory act in question.

Florida Department of TRANSPORTATION

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

DISCRIMINATION/SEXUAL HARASSMENT COMPLAINT FORM

275-610-01 EQUAL OPPORTUNITY 11/11

COMPLAINANT INFORMATION

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

275-610-01
EQUAL OPPORTUNITY
11/11