New Jersey Judiciary Formal Discrimination / Sexual Harassment / Retaliation COMPLAINT FORM Please type or clearly print all information. DATE FILED: ________________________________ COMPLAINANT INFORMATION MIDDLE NAME FIRST NAME LAST NAME (include: Sr. / Jr. / III, etc.) HOME ADDRESS CITY HOME TELEPHONE STATE ZIP WORK TELEPHONE JOB TITLE VICINAGE / DIVISION / AOC COMPLAINANT STATUS (CHECK APPLICABLE BOX) If you check “other” specify whether: OTHER VOLUNTEER JUDICIAL EMPLOYEE JOB APPLICANT VENDOR PROBATIONER OTHER (LITIGANT, WITNESS, ETC.) ___________________ (SPECIFY) NAME AND TITLE OF PERSON(S) YOU BELIEVE DISCRIMINATED AGAINST YOU NAME JOB TITLE VICINAGE / DIVISION / AOC NAME JOB TITLE VICINAGE / DIVISION / AOC NAME JOB TITLE VICINAGE / DIVISION / AOC BASIS OF COMPLAINT (CHECK APPLICABLE BOX OR BOXES) RACE COLOR SEX / GENDER NATIONAL ORIGIN / NATIONALITY GENDER IDENTITY OR EXPRESSION USE OF GENETIC INFORMATION, INCLUDING REFUSAL TO SUBMIT TO OR PROVIDE RESULTS OF GENETIC TEST CIVIL UNION STATUS DOMESTIC PARTNERSHIP STATUS ANCESTRY DISABILITY / PERCEIVED DISABILITY RELIGION / CREED AGE AFFECTIONAL OR SEXUAL ORIENTATION ATYPICAL HEREDITY CELLULAR OR BLOOD TRAIT MARITAL STATUS VETERAN STATUS OR LIABILITY FOR MILITARY SERVICE SEXUAL HARASSMENT RETALIATION Description of Complaint: List each incident separately and describe in detail the incident(s) and time and place of occurrence. NOTE: A copy of this form will be provided to the person(s) against whom you are filing a complaint. Therefore you should not identify witnesses or background evidence on this form. You will be asked to submit that material separately to the investigator who will investigage your complaint. DESCRIPTION OF INCIDENT DATE OF INCIDENT WAS INCIDENT REPORTED TO ANYONE? IF YES, WHO? DATE REPORTED Revised: 7/2007 Catalog Number: 10493-English Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com DESCRIPTION OF INCIDENT DATE OF INCIDENT WAS INCIDENT REPORTED TO ANYONE? IF YES, WHO? DATE REPORTED DESCRIPTION OF INCIDENT DATE OF INCIDENT WAS INCIDENT REPORTED TO ANYONE? IF YES, WHO? DATE REPORTED DESCRIPTION OF INCIDENT DATE OF INCIDENT WAS INCIDENT REPORTED TO ANYONE? IF YES, WHO? DATE REPORTED DESCRIPTION OF INCIDENT DATE OF INCIDENT WAS INCIDENT REPORTED TO ANYONE? IF YES, WHO? DATE REPORTED REMEDY SOUGHT (EXPLANATION) ADDITIONAL PAGES MAY BE ATTACHED NOTE: The Complainant has a right to use the external procedures available under state law (Division on Civil Rights) and federal law (Equal Employment Opportunity Commission). Information regarding external procedures is contained in the Policy Statement and on posters located in the Human Resouces Office. LOCAL EEO/AA OFFICER / REGIONAL INVESTIGATOR SIGNATURE DATE COMPLAINANT’S SIGNATURE DATE The completed form is to be given to the local EEO/AA Officer or to the Chief Judiciary EEO/AA Officer in the AOC. Revised: 7/2007 Catalog Number: 10493-English Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com