North Carolina Department of Public Safety
Equal Employment Opportunity Office
EEO Complaint Form

Name:

Home phone with area code: Cell Phone:

Mailing Address: 

Work location: Work Telephone:
Division: Position Title:
Facility: Work Hours:
Work Location: Immediate Supervisor:
Type of Complaint:
Discrimination
Workplace Harassment
Retaliation
Other (please specify)
Basis of Charge:
Race National Origin
Sex Age
Creed Disability
Religion Color
*Genetic Information Political Affiliation
*Complaints based on Genetic Information are limited to the DPS internal grievance process.
Provide the name and title of individual you are filling the charge against:
Most recent date of the alleged act:
Description of charges - Must provide a narrative description of the complaint including what happened, dates(s) of alleged incidents(s), the harrasser(s) or respondents(s) and witnesses, including their full names, position titles, and work locations, if known.
Supporting documentation may be faxed to (919) 716-3958. Please include your full name, work location, and contact number.


Please click submit only once and wait for confirmation that your submission was received.