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Department of Public Works. . ....
1106 Second Street .. ... ... . ..
Eureka, CA 95501-0579 ... ..........
Ph: (707) 445-7491
Note: The use of the complaint form is not mandatory. You may submit your complaint in any form that includes your signature. Please sign
and date the complaint form below.
If you have a representative, please provide the following information:
Please describe the circumstances of the alleged discrimination and include date(s).
Please be sure to explain as clearly as possible the nature of the action, what happened and why you believe your protected status (basis) was
a factor in the discrimination. Include how other persons were treated differently from you. (Attach additional page(s), if necessary).
Names of individuals responsible for the discriminatory action(s):
Names of individuals (witnesses, fellow employees, supervisors, or others) whom we may contact for additional information to support or
clarify your complaint:
The laws prohibit retaliation against anyone because he/she has taken action, or participated in an action, to secure rights protected by these
laws. If you feel you have been retaliated against (separate from the discrimination alleged above), please explain the circumstances below.
Please explain what actions you took which you believe were the basis for the allegation.
What remedy, or action, are you seeking for the alleged discrimination?
Has complainant filed a lawsuit regarding this complaint? If yes, please specify:
Have you filed, or intend to file, a charge or complaint regarding the matters raised in this compliant with any of the following?
If you have already filed a charge or complaint, please provide the following information:
Please provide any additional information that you believe would assist in the investigation:
This field is not part of the form submission.
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