EMPLOYMENT DISCRIMINATION COMPLAINT


I. GENERAL INFORMATION

Name: _____________________________ Social Security Number:________________

Mailing Address:___________________________________________________________

Home Phone Number: ____________________ Contact Phone:_____________________

II. EMPLOYMENT INFORMATION (Current or former state employee only)

Date of Hire: __________________ Present Job Title:________________________

Department: __________________________ Division: __________________________

Phone: ___________

Work Address:______________________________________________________________

Supervisor's Name: ______________________________ Title: ___________________


III. APPLICANT INFORMATION (Applicant for state employment only)

Job Class (Title) you applied for: ________________________________________

If you responded to a letter from a department which invited you to apply
for a vacancy, please provide the following information:

Department:_____________________ Division:_________________________________

Date: ____ Contact Person:_______________Were you interviewed?Yes ___ No___

IV. TYPE OF DISCRIMINATION (Check applicable)

___  Race               ___  Change in Marital Status  ___  Pregnancy
___  Sex                ___  Religion                  ___  Veteran Status
___  Sexual Harrassment ___  Color                     ___  Age **
___  Disability         ___  Retaliation *             ___  National Origin
___  Marital Status     ___  Parenthood               


* AS 44.19.456 RETALIATION PROHIBITED

(a) Any agency, officer, or state employee may not directly or indirectly
 refuse to hire, transfer, or promote, or dismiss,demote, suspend, lay
 off, or otherwise discipline a person for filing a complaint with the
 office for a failure to comply with affirmative action or equal employment
 opportunity or for assisting the office in an investigation of a complaint.

** The Age Discrimination in Employment Act of 1967 ADEA protects individuals
 who are 40 years of age or older from discrimination based on age.

V. DATE OF MOST RECENT DISCRIMINATORY ACT OR PRACTICE

Month: __________________ Day: ______________________ Year:________________

(Note: Discrimination must be ongoing or must have occurred within 90 days
 of the complaint filing to utilize the OEEO informal complaint process)





VI. OTHER COMPLAINT INFORMATION

Have you filed this complaint with the Alaska State Commission for
Human Rights or the federal Equal Employment Opportunity Commission?
Yes _____ No _____

Have you filed this complaint through a collective bargaining agreement
union process? If so, please give the date filed and current step of the
grievance. Date: ____________ Step: ________

Have you consulted with an attorney? Yes _____ No______



VII. BRIEFLY DESCRIBE INCIDENTS YOU BELIEVE WERE ACTS AND/OR WORDS OF
DISCRIMINATION.  INCLUDE NAMES AND DATES. ATTACH SUPPORTING DOCUMENTATION,
IF AVAILABLE. ATTACH ADDITIONAL SHEETS AS NEEDED.
(Note: You are responsible for retaining copies of the information you
provide the OEEO. All information received by this office becomes property
of the office and will not be returned.)

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VIII. IN WHAT WAY WOULD YOU LIKE TO SEE THIS MATTER RESOLVED?  ATTACH
ADDITIONAL SHEETS AS NEEDED.
___________________________________________________________________________

I affirm that all statements regarding this alleged incident of
discrimination are true and factual to the best of my knowledge.

Complainant's signature: ________________________ Date: ________

All information received by the Office of Equal Employment Opportunity

during the course of a complaint investigation is confidential and will
not be provided to unions or other investigative agencies.