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["County of Gloucester "]
["Human Resources Manual "]
[]
["CHAPTER 7:",null,null,"CONDUCT AND PERFORMANCE",null,null,null,null,null,null,"ADOPTED:","2009-11-04"]
["SECTION 7:",null,null,"PROHIBITION OF DISCRIMINATION, HARASSMENT",null,null,null,null,null,null,"REVISED:","2024-05-22"]
[null,null,null,"OR HOSTILE ENVIRONMENTS IN THE WORKPLACE"]
[]
["Discrimination Complaint Processing Form  - Exhibit A"]
[]
["INSTRUCTIONS: This complaint form should be filed with the County's Equal Employment Opportunity Officer. "]
["For detailed information on the complaint process, see the \"County of Gloucester Model Procedures for Processing Internal Complaints"]
["Alleging Discrimination in the Workplace\" on Page 2 and 3 of HR 7.7 Exhibit A. "]
["1. Name: ",null,null,null,null,null,"2. Telephone (Work): "]
["3. Department/Job Title:",null,null,null,null,null,"4. Telephone (Home/Mobile): "]
["5. Home Address: ",null,null,null,"6a. Full name, title, and telephone number of person(s) you believe discriminated against you: "]
[]
["6b. Date(s) of discriminatory action(s): "]
[]
[]
["6c. Complainant's Status (Check applicable box:)    "]
[]
["7. Basis of Discrimination: "]
[]
[]
[null,null,null,null," ",null,null,null,null,"      (including pregnancy) "]
[null,null,null,null,"(including refusal to submit to or provide results of a genetic test) ",null,null,null,null," "]
[null,null,null,null,"  "]
[" ",null,null,null," ",null,null,null,"(for having filed a discrimination complaint, investigation, or for opposing a discriminatory practice) "]
[]
[" ",null,null,null," ",null,null,null,null," "]
["8a. Explain why you feel you have been discriminated against: "]
[]
[]
[]
["8b. Were the actions or behavior you are complaining about directed at, or said to, you __ and/or another party __ (third party harassment)?"]
[]
["8c. Was the incident reported to anyone? YES __ NO __ If yes, who and when? _________________________________________"]
[]
["8d. What remedy or resolution are you seeking? __________________________________________________________________"]
[]
["8e. If appropriate, as determined by the EEO Officer, are you willing to attempt to resolve your complaint through mediation or another  "]
["     alternative dispute resolution (ADR) process?  "]
[]
["8f. Complainant's Signature: ",null,null,null,null,null,null,null,"Date:"]
["9. Have you filed a discrimination complaint with the ",null,null,null,null,null,null,null,"10. Have you filed a grievance on the issues / "]
[null,"• N.J. Division on Civil Rights? ",null,null,null,null,null,null,"personnel actions described? "]
[]
[null,"• U.S. Equal Employment Opportunity Commission? "]
[]
["11. Completion of this part is voluntary. The information is to be used only for State and Federal record keeping and reporting requirements: "]
["SEX:",null," ",null," "]
["RACE:"]
["ETHNICITY: "," ",null,null,null,null,null,"       "]
["Note: In addition to filing an internal complaint, a Complainant has a right to use external complaint filing procedures available under state law (with the NJ Division of Civil Rights) and federal law (with the US Equal Employment Opportunity Commission). Detailed information is contained in the Model Procedures beginning on Page 2 of this form. "]
["DO NOT WRITE BELOW THIS LINE "]
[]
["EEO/AA Officer Signature: ",null,null,null,null,null,null,null,"Date Received: "]
[]
["Page 1 of 3 "]
["7.7 EXHIBIT A - COMPLAINT PROCESSING FORM (PRE-INTAKE QUESTIONNAIRE)"]