Governor Napolitano's Office of Equal Opportunity

Employment Discrimination
Complaint/Intake Questionnaire

Complainant Information: (All fields are required and must have a response)
First Name:	Last Name:
Address:
City:	State: Zip:
Home Phone:	Other Phone:
E-mail:
Date of Birth:	Gender: Male Female No Response

Basis on which you believe you have been discriminated against: (Select all applicable)
Race	Pregnancy	Religion	Age	Harassment
Sex	National Origin	Disability	Sexual Orientation
Color	Marital Status	Retaliation	Other

National Origin/or Ethnic Group: (Please select one)
White	African American	Asian American	Arab, Afghani, Middle Eastern
East Indian	American Indian	Hispanic	Other
No Response

State Agency Against Which Complaint is Being Filed:
Agency/Employer:	Division/Dept: # of Employees:
Supervisor Name:	Supv. Phone:
Address:
City	State: Zip:


Complaint/Discriminatory Incident(s) Description: In date order (chronologically), describe the harm or employer action for which you are filling a complaint. Be sure to include dates, times, names of witnesses, and what specifically was said and/or happened.

I swear to the best of my knowledge and belief that the information contained herein is complete and accurate.
Name: Date:

Your rights to privacy are of utmost importance to the Governor’s Office in building trust and confidence when conducting business through the Internet. The Governor's Office will attempt to protect the privacy interest of anyone who corresponds with the Governor's Office and does not wish their contact information to be made public; however, because the Governor's Office is a public entity, there can be no guarantee that such information will always be kept confidential.




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