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Free Employee Complaint Form Pdf
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GENERAL NATURE OF COMPLAINT: (please check all applicable boxes and provide dates on lines provided)
 I believe I am a victim of Retaliation or Workplace Violence.
I believe I was
 suspended on or about
demoted on or about
 transferred on or about
 warned on or about
 poorly evaluated on or about
 placed on probation on or about
 not accommodated on or about
 denied equal services on or about
harassed on or about
 sexually harassed on or about
 earning unequal pay on or about
 denied a raise on or about
 not promoted on or about
 delegated unusual duties on or about
on or about
I believe I have been discriminated against based on one or more of the following:
 Race  Age (over 40)
Sex Color
 National Origin  Religion/Creed
 Sexual Orientation  Physical Disability
 Mental Disability/Disorder  Learning Disability
 Marital Status  Prior Criminal Record
 Other:
Do you know of other employees or applicants of your group (basis of discrimination above) who were treated
the same way you allege you were If yes, provide names, titles, race, sex, etc., and explain.
 YES  NO
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