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

 

County Employee and Citizen EEO Intake Form

This is the form the complainant should complete to file an equal employment opportunity (EEO) discrimination and/or harassment complaint. Please call (813) 903-3335 if you need assistance in completing this form and/or to make an appointment to speak with an investigator, if you have not already done so.

1. COMPLAINANT

Please Choose One: Citizen -- OR -- Employee
Please Choose One: Mr. Mrs. Ms.
       
Name:
 
Last
First
Middle
       
Job Title/Position:
   
Department Name (if county employee):
Place of Employment (if citizen):
       
Work Street Address:
City:
State:
Zip Code:
Work Telephone Number: ( ) - -
           
Home Street Address:
City:
State:
Zip Code:
Home Telephone Number: ( ) - -

2. BASIS OF THE COMPLAINT: (Check all that apply)
Race
Color
National Origin
Gender
Religion
Disability
Veteran’s Status Marital Status
Age
Retaliation
Pregnancy
Sexual Harassment Other:

3. RESPONDENT: (Person you believe to be responsible for the alleged discrimination and/or harassment.)

Name:
 
Last
First
Middle
       
Department Name:
Address:
City:
State:
Zip Code:
Work Telephone Number: ( ) - -

4. LAST DATE DISCRIMINATION AND/OR HARASSMENT OCCURRED: (The date of the most recent alleged discrimination and/or harassment incident.)

5. DISCRIMINATON AND/OR HARASSMENT STATEMENT: (Describe in detail how you were treated differently because of your race, color, national origin, gender, religion, disability, veteran status, marital status, age, or pregnancy; how you were retaliated against or sexually harassed. Provide the first and last names of all people involved.)

6. RESPONDENT’S REASON FOR BEHAVIOR: (Did the person who discriminated against and/or harassed you give any reason for his/her actions? If not, write “No reason given” in the space provided.)

7. HARM SUFFERED: (i.e., Termination, Transfer, Suspension, Demotion, Poor Work Evaluation, etc.)

8. HAS THIS ALLEGATION BEEN FILED ANYWHERE ELSE? : (for example, EEOC, Florida Commission on Human Relations, etc.)

Yes
  
No
  

If yes, provide the following information:

Name of Agency:
Contact Person:
Telephone Number: ( ) - - Date of filing (mm/dd/yyyy):

9. RELIEF SOUGHT : (What would you like to see happen as a result of this review?)

10. IDENTIFY THE WITNESSES WHO HAVE FIRSTHAND KNOWLEDGE REGARDING THE INCIDENTS YOU HAVE DESCRIBED IN THIS COMPLAINT :

Witness Name:
Telephone Number: ( ) - -
Address:
Relationship to
Complainant (if any):
What does the witness know?:
         
Witness 2 Name:
Telephone Number: ( ) - -
Address:
Relationship to
Complainant (if any):
What does the witness know?:

11. COMPARATORS: (Are there any people who were treated differently than you who were in the same or similar situation regarding the incidents you described in section 5? If yes, please list the name(s) of the person(s) treated differently than you.)

1.)

2.)

12. HAVE YOU PREVIOUSLY INFORMED ANY SUPERVISOR OF THE DISCRIMINATORY OR
HARASSING INCIDIENTS WHICH YOU DESCRIBE IN THIS COMPLAINT?

Yes No    
If yes, please complete the information below:
Name of the supervisor:
Department Name:
Work Telephone Number: ( ) - -  
   

This questionnaire is for Hillsborough County internal review only. If an investigation is warranted, it will be an administrative investigation only. You have the right at any time to file your complaint with the Florida Commission on Human Relations “FCHR” (state agency) or with the Equal Employment Opportunity Commission “EEOC” (federal agency).

I affirm that, to the best of my knowledge, the information contained herein is true and factual. I understand that the completion of this form or the filing of a complaint with the Consumer Protection and Professional Responsibility Agency- Professional Responsibility Section does not extend the time for filing a complaint with an outside agency, or in a court of law.

Complainant’s Signature: _________________________________________________________
Date:

 

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,
    EEO Manager
    Consumer Protection and Professional Responsibility Agency
    8900 N. Armenia Ave., Suite 226
    Tampa, FL 33604


If you have any questions regarding the completion of this form, please contact:

  • Camille Blake at (813) 903-3335