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Click ‘Get Form’ to open it in the editor.
Begin by entering your name and contact information in the designated fields. Ensure that you provide both work and home telephone numbers, indicating if your home number is unlisted.
Fill in the details of the agency and division involved, along with the names of individuals who allegedly discriminated against you. Clearly state their relationship to you, such as direct supervisor or co-worker.
Document the dates of the earliest and latest occurrences of events related to your complaint. This helps establish a timeline for your case.
In the section detailing how you were discriminated against, provide a comprehensive explanation of what transpired, including specific actions taken by individuals involved.
Describe any differential treatment you experienced compared to others. If applicable, indicate whether other employees were treated better under similar circumstances.
Conclude by stating what resolution you seek from this complaint and any additional relevant information that may support your case.

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