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e-mail: Silvia.vaccaro@state.mn.us

fax: 651-201-5779
Minnesota Department of Health

Office of Workforce Diversity

Discrimination/Harassment Complaint Form




*Please Read Before Completion of Form*

TENNESSEN NOTICE: This form asks you to supply data concerning yourself that may be considered private or confidential under the Minnesota Government Data Practices Act (MN. Stat., Chapter 13). The reason this data is being collected is to help the Department of Health understand and investigate a complaint that you wish to file alleging discrimination or harassment. Although you are not legally required to supply the requested data, failure to do so may make it difficult for the department to investigate your complaint. While providing data may put you at risk in terms of possible legal action that could be taken against you, the consequences of not supplying the data would be that we do not have all of the information relevant to your complaint. If you supply this data, you may be required to testify at subsequent hearings and/or data you provide may be used to take disciplinary or other remedial action.

The other persons or entities which, as authorized by law, may see the data at some point include: supervisors and managers whose input is necessary in the decision-making process; exclusive representatives of employees; staff of Minnesota Management and Budget; persons and/or entities authorized by you to see the data; arbitrators, hearing examiners and other judicial and/or quasi-judicial officials; and other entities involved in grievances, appeals and litigation over the subject matter of this investigation (includes the Attorney General’s office). This could include the: State and federal courts; State and federal human rights enforcement agencies; the Re-employment Compensation Division of the Minnesota Department of Employment and Economic Development; law enforcement agencies; counsel for and parties to litigation pursuant a court order; the Legislative Auditor’s office; the employee who is being investigated.

Name of Complainant  

Division/Section/Unit  

Job Title  

Supervisor  

Phone  

E-mail  

Check any of the following that you believe may be the basis for the complaint:

 Disability
 Race
 Sex
 Age
 Color



 National Origin
 Religion
 Creed
 Sexual Orientation
 Marital Status

 Status with Regard to Public Assistance
 Local Human Rights Commission Activity
 Retaliation for filing prior complaint
If so, date of complaint      



Why do you believe the reason(s) you checked above is the basis of your complaint?

 
Who do you believe discriminated against or harassed you?

Name  

Division/Section/Unit  

Phone  
Please describe the reason (or reasons) you believe that you were discriminated against or harassed.

Describe the incident(s) in detail, with the most recent incident first (include names and types of behavior, dates, times, locations). Attach additional sheets if necessary. If you have documentation you believe is relevant to your complaint, please attach it to this complaint form.

 

1.



Yes



No

Has an act of physical violence occurred?

2.



Yes



No

Has intimidation or a threat of violence occurred?

3.



Yes



No

Did police or security respond to this incident? If yes, who responded?

4.



Yes



No

Was a police report filed? List Jurisdiction and report number.

5.



Yes



No

Was your supervisor notified? When?

6.



Yes



No

Was a weapon involved? If yes, specify.

7.



Yes



No

Were you alone when the incident occurred? List the names of any witnesses.

8.



Yes



No

Were you injured? Describe the nature of the injuries and list any facility where you were treated.

9.



Yes



No

Did you lose any work time as a result of this incident? Explain.



Were there any witnesses? If so, who?

Witness #1

Name  

Division/Section/Unit  

Phone  



What did he/she observe?

 


Witness #2

Name  

Division/Section/Unit  

Phone  



What did he/she observe?

 
Did you attempt resolution of this matter through any other process, such as a union grievance, mediation or other process? If so, please specify.

 
Did you file this complaint with any other agency? If so which agency and where is it in the process?

 


This complaint is being filed based on my honest belief that the named person(s) discriminated or harassed me. I hereby certify that the information I have provided in this complaint is true, correct, and complete, to the best of my knowledge and belief. I hereby affirm that I am not using this complaint procedure for reasons of personal malice or abuse towards another employee.
_______________________ ____________________

Signature Date


_______________________ ____________________

Received by Date


S
Send completed form to:

e-mail: Silvia.vaccaro@state.mn.us



fax: 651-201-5779
aved on 8/12/2013 08:10:00 PM


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