HTML Preview Employee Complaint Investigation page number 1.
CFN 552-0318 Revised 12/07/16 Page 1 of 4
State of Iowa
Iowa Department of Administrative Services
Human Resource Enterprise
Employee Complaint Form
If you believe that you have been unlawfully discriminated against, harassed, retaliated against or feel that a violation of
either the State’s Violence-Free Workplace Policy or Equal Opportunity, Affirmative Action, and Anti-Discrimination Policy
has occurred, please fill out this form and return it to the Department of Administrative Services – Human Resources
Enterprise Attn: Employee Relations as instructed on page 4 of this form. Please type or print legibly.
YOUR PERSONAL INFORMATION
1.
Legal name:
2.
Department you work in:
3.
Job title:
4.
Home mailing address (correspondence will be sent to this address):
Street (Apt. No.)
City
State
Zip Code
5.
Contact information (complete all avenues you prefer we use to communicate with you during the complaint process):
Phone (required)
Work
Home
Cell
Email (required)
Work
Personal
FACTORS RELATING TO YOUR COMPLAINT - Following are a series of questions designed to help us identify all of the
factors relating to your complaint. Please do not skip an answer. If the basis does not apply, select “No.”
6.
Do you believe you were discriminated against because of your race/ethnic group? If yes, please
check the affirmative action group that represents your race/ethnic group.
☐No ☐Yes
☐
(0) White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa
☐
(1) Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial
groups of Africa
☐
(2) Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian Subcontinent
☐
(3) American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original
peoples of North or South America (including Central America), and maintain tribal affiliation or community
attachment
☐
(4) Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, Central or South American or other
Spanish culture or origin, regardless of race
☐
(5) Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the
peoples of Hawaii, Guam, or other Pacific Islands
☐
(6) Two or More Races (Not Hispanic or Latino) –All persons who identify with more than one of the above six
races