STATE OF CALIFORNIADEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT

DISCRIMINATION COMPLAINT FORMOFFICE OF THE DIRECTOR

HCD DIR 8 (REV 6/15)Equal Employment Opportunity (EEO) Office

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It is the policy of the Department of Housing and Community Development (HCD), as required by federal and state laws, to provide a work environment free of discrimination. Please refer to HCD’s Equal Employment Opportunity (EEO) policies for more information. This form may be used by HCD employees or job applicants applying for a position within HCD. To initiate a complaint of discrimination within HCD, this form must be filed with the EEO Office within 365 daysof the last act of discrimination. When filing a complaint, HCD employees have a right to confidentiality to the extent possible. Any form of retaliation against an employee for filing a complaint may be cause for disciplinary action.
I. COMPLAINANT’S INFORMATION:
Complainant’s Name / Race/Ethnicity(optional) / Age (optional) / Gender (optional)
Classification / Job Title
Division/Branch/Unit / Immediate Supervisor
Work Mailing Address / Work Phone Number
Home Mailing Address / Home Phone Number
Personal E-mail Address (optional)
Date(s) of Discriminatory Treatment / Date of Last Discriminatory Act
II. RESPONDENT’S INFORMATION - PERSON(S) AGAINST WHOM YOU ARE FILING A COMPLAINT
(If more than one respondent list others under Section V):
Respondent’s Name / Classification
Work Location / Work Phone Number
Respondent’s Relationship To Complainant
III. BASIS FOR COMPLAINT - PROTECTED GROUP CATEGORY: [Check appropriate box(es)]
☐Age (40 or older)
☐Ancestry
☐Color
☐Denial of Family and/or Medical Care Leave
☐Denial of Pregnancy Disability Leave
☐Denial of Reasonable Accommodation
☐Disability (physical or mental)
☐Gender (including gender identity/expression)
☐Genetic Information
☐Marital Status / ☐Medical Condition (cancer related or genetic characteristics)
☐National Origin
☐Political Affiliation
☐Race
☐Religion
☐Retaliation (reprisal)
☐Sex (including sexual harassment or pregnancy)
☐Sexual Orientation
☐Veteran Status/Military Leave
☐Other (specify)
IV. HARM - REASON(S) YOU BELIEVE THE CONDUCT IS DISCRIMINATORY:
☐ Abusive Conduct (specify basis/connection with protected group category):
☐ Denial of Reasonable Accommodation
☐ Disparate Treatment
☐ Harassment (specify basis):
☐ Retaliation
☐ Working Conditions
☐ Other (specify):
V. Name(s) of other respondent(s). Include classification, work location, work phone number, and relationship to complainant for each respondent. Complete this section only if applicable.
VI. Summarize the nature of this complaint – include date(s) and description of actions, decisions, or conditions which caused you to believe you have been discriminated against. You must complete this section. (Attach additional pages if necessary). If this section is not completed, the form will be returned to you for completion.
VII.Name(s) of witness(es) or other person(s) who may have information regarding the complaint.
Briefly explain what you think each witness will be able to tell us. Include classification, work location, work phone number, and relationship to complainant for each witness.
VIII.Specify remedy requested.
IX. STEPS TAKEN PRIOR TO FILING COMPLAINT:
Was matter discussed with respondent(s)?
Was matter discussed with your supervisor?
Was matter discussed with anyone else? / ☐YES ☐NO
☐YES ☐NO
☐YES ☐NO
Complainant’s Signature / Date

PERSONAL INFORMATION NOTICE

Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to (916) 263-3635 or 711 California Relay Service.

Discrimination Complaint Process

Employee Rights

A discrimination complaint must be filed with HCD’sEEO Office within 365 days of the last act of discrimination. The complaint must state the action perceived to be discriminatory, the basis of discrimination, and the specific remedy(ies) sought by the complainant.

When a complaint is filed, the complainant must understand that anonymity provisions do not apply. HCD will make every effort to insure that confidentiality is maintained, to the extent possible, in accordance with the applicable federal and state laws.

HCD employees’ rights and responsibilities with regard to complaints of discrimination:

  • To file concurrently with the Department of Fair Employment and Housing (DFEH) and Equal Employment Opportunity Commission (EEOC).
  • To an impartial investigation.
  • To provide accurate and factual information during all phases of the complaint process. Truth is expected from all persons involved in the investigative process.
  • Freedom from restraint, interference, coercion, or retaliation.
  • To file a complaint with the State Personnel Board (only for discrimination based on disability, medical or mental condition, including denial of reasonable accommodation), DFEH, or EEOC if complainant does not agree with the outcome of the investigation.

I have read and understand these rights.

Print Name / Signature / Date

Please submit completed form to the EEO Office, 2020 W. El Camino Avenue, Suite 461, Sacramento, CA 95833.