Person Filing the Complaint
Complainant Name
*
First Name
Last Name
Complainant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Complainant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Complainant Email
*
example@example.com
Person Discriminated Against (if other than person filing the complaint)
Name of Person Discriminated Against
First Name
Last Name
Address of Person Discriminated Against
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Person Discriminated Against
Please enter a valid phone number.
Format: (000) 000-0000.
Incident Details
Date of Incident
*
-
Month
-
Day
Year
Note: If you can't remember the exact date, please use an estimated date.
Location of Incident
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List the Alaska DEC employee(s) or DEC program involved in the incident
List name, office or department and position, if known
What was the discrimination based on? (Check all that apply)
Race/Color
National Origin
Age
Sex
Disability
Limited English Proficiency
Describe how you were discriminated against
What happened and who was responsible?
Witness Contact Information
Witness Name
First Name
Last Name
Witness Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Witness Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Have you filed this complaint with another federal, state, or local agency; or with a federal or state court?
Yes
No
Check each agency where a complaint was filed
Federal Agency
State Court
Federal Court
Local Agency
State Agency
Other
Please provide contact information for the agency that also received the complaint
Agency Contact Name
First Name
Last Name
Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I certify that to the best of my knowledge and belief the statements and information on this form are true, accurate, and complete.
*
Yes, I certify the above statement
No, I do not certify the above statement
Signature
*
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: