county seal
Printed from: http://hillsboroughcounty.org/consumerprotection/departmentmainpage/professionalresponsibility/incidentreportform.cfm on 11/21/2009
Consumer Protection and Professional Responsibility Agency
Professional Responsibility Section

 

Incident Report Form for use by Management Personnel
to report Equal Employment Opportunity Issues

Please complete this form if the employee has stated that he/she wishes to file a complaint.

Contact Information of Supervisor/Manager Reporting the Incident

Name:
Work Telephone Number: ( ) - -
Mail Point:
Department Name:
Job Title/Position:
Date this Document is Completed:
Date, Time, and Location of Alleged Incident:
   
Type of Complaint
Check All That Apply
Race Disability Pregnancy
Religion Veteran’s Status Retaliation
Sexual Harassment National or Ethnic Origin Marital Status
Age Gender Color
 
Other:
           
Type of Action or Behavior
Check All That Apply
Inappropriate Language or Statements Co-worker Issue
Promotion Hiring
Termination Layoff
Unwanted Physical Contact Supervisor/Manager Issue
Working Conditions    
  Other:
Person Making the Complaint to You
(Complainant)
Name:
 
Last
First
Middle
Job Title/Position (complete if the complainant is a county employee):
Place of Employment (if citizen)/Department Name (if county employee):
Work Address:
 
Street
City
State
Zip
Work Telephone Number: ( ) - -
Home Address:
 
Street
City
State
Zip
Home Telephone Number: ( ) - -
   
   

Person the Complaint Was Made Against
(Respondent)

Name:
Position/Title:
Department Name:
Work Telephone Number: ( ) - -

Detailed Statement of Alleged Incident

Statement of Action Taken by Supervisor (if any)

ROUTING INSTRUCTIONS
When you are finished filling out this form

  • Click on the submit button
  • Print out the confirmation page
  • Sign the printed hard copy
  • Forward the completed and signed form to the address below:

    Camille Blake
    Equal Employment Opportunity Manager
    Consumer Protection and Professional Responsibility Agency
    8900 N. Armenia Ave., Suite 226
    Tampa, FL 33604