Contact Information

Name

Discrimination Basis

Prohibited discrimination or harassment includes actions taken based on race, color, ethnicity, sex (including equal pay/compensation, pregnancy, gender identity, or gender expression), religion, national origin, age, disability (physical or mental), requests for reasonable accommodation, military service or veteran status, sexual orientation, marital or parental status, genetic information or family medical history, retaliation/reprisal (for prior EEO activity), or other non-merit factor.

These categories are referred to as basis.  Check and specify all that apply.

Discrimination Checkboxes

Sex:

Disability:

*Protected by Executive Orders 13087, 13145, and 13152 and are not enforced by federal statute.

Documentation

Please attach any documentation you wish to submit to support your allegation(s).  Include a copy of any written action(s) that caused you to seek counseling at this time.
One file only.
100 MB limit.
Allowed types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml avi mov mp3 ogg wav bz2 dmg gz jar rar sit svg tar zip.
CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.