EEO Discrimination Complaint Processing Form

State of New Jersey Civil Service Commission
Office of Equal Employment Opportunity and Affirmative Action
Discrimination Complaint Processing Form
INSTRUCTIONS: This complaint form can be completed by a complainant or with the assistance of the Equal Employment Opportunity/Affirmative Action Officer or the alternate designee for the State department, agency, commission, or State college/university where you work or applied for employment.
Name:*

First NameLast Name
Name of State Dept., Agency, Commission or College:
Telephone (Work):
Please enter a valid phone number.
Job Title:
Division/Office/Facility:
Telephone (Home):*
Please enter a valid phone number.
Telephone (Cell):*
Please enter a valid phone number.
Email*
example@example.com
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date(s) of discriminatory action(s):*
Full name, title, and telephone number of person(s) you believe discriminated against you:
Complainant's Status (Check applicable box):*

EmployeeJob ApplicantVendor/ContractorOther
Basis of Discrimination:*

AgeAffectional/Sexual OrientationAncestryAtypical Hereditary Cellular or Blood TraitColorCreedDisabilityDomestic Partnership StatusFamilial StatusGender Identity or ExpressionGenetic Information (including refusal to submit to or provide results of a genetic test)Liability for Military ServiceMarital/Civil Union StatusNationalityNational OriginPregnancyRaceReligionSex/GenderSexual HarassmentRetaliation (for having filed a discrimination complaint, participating in a complaint investigation, or for opposing a discriminatory practice)Unknown
Explain why you feel you have been discriminated against:*
Were the actions or behavior you are complaining about directed at, or said to you*

and/or another party(third party harassment)?
Was the incident reported to anyone?*

YesNo
If yes, who and when?
Date

MonthDayYear
What remedy or solution are you seeking?
If appropriate, as determined by the EEO Officer, are you willing to attempt to resolve your complaint through mediation or another alternative dispute resolution (ADR) process?

YesNo
Complainant's Signature*

Clear
Date

MonthDayYear
Have you filed a complaint with:
N.J. Division on Civil Rights?*

YesNo
U.S. Equal Employment Opportunity Commission?*

YesNo
Have you filed a grievance on the issues/personnel actions described*

YesNo
Completion of this part is voluntary. The information is to be used only for State and Federal record keeping and reporting requirements:
SEX:

MaleFemaleNon-Binary
RACE:

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
ETHNICITY:

Hispanic or LatinoNot Hispanic or Latino
Note: In addition to filing an internal complaint, a complainant has a right to use external complaint filing procedures available under State law (with the NJ Division of Civil Rights) and federal law (with the US Equal Employment Opportunity Commission)
Please verify that you are human*
Should be Empty:

State of New Jersey Civil Service Commission

Office of Equal Employment Opportunity and Affirmative Action

Discrimination Complaint Processing Form