Office of Equal Opportunity Programs (OEOP)

Employment Discrimination/Hostile Work Environment Complaint Form

This complaint form is to be completed by Maryland Department of Health employees and applicants for employment, and individuals doing business with the Maryland Department of Health, and its entities, such as clients, vendors, and contractors.

Pursuant to State Personnel and Pensions, §5–209(a), An employee in the skilled service, professional service, or management service of the State Personnel Management System may elect to pursue an allegation of employment discrimination under: (1) the complaint procedures in this subtitle; or (2) the grievance procedures in Title 12 of this article. Both complaint processes cannot be utilized to pursue an allegation of employment discrimination. The complaining party must choose one process when pursuing an allegation of employment discrimination.

Please CLEARLY PRINT or TYPE the following information (add additional pages as needed):

Last Name: First: MI:

Home Address:

City: State: Zip Code:

Phone: Work Phone: Email:

Title: Department/Location:

Supervisor’s Name: Supervisor’s Contact Number:

Name and work locations of individual(s) you believe discriminated against you:

What is the basis of the alleged discrimination? (Check only those that apply to your complaint)

Age	Sex (gender)	Mental or Physical Disability	Color

Retaliation*	Genetic Information	Sexual Orientation	Ancestry

Religion	Marital Status	Creed	National Origin

Race	Gender Identity and Expression

*Retaliation is defined, by the EEOC as filing or being a witness in an EEO charge, complaint, investigation, or lawsuit; communicating with a supervisor or manager about employment discrimination, including harassment; answering questions during an employer investigation of alleged harassment; refusing to follow orders that would result in discrimination; resisting sexual advances, or intervening to protect others; requesting accommodation of a disability or for a religious practices; asking managers or co-workers about salary information to uncover potentially discriminatory wages.

What issues are associated with your complaint? (Circle only those that apply to your complaint)

Recruitment	Failure to Hire	Performance Evaluation

Demotion	Discharge	Sexual Harassment

Transfer	Promotion	Working Conditions

Hostile Work Environment	Other _____________________________________

Bullying

When did the alleged discrimination occur?

Date:

Where did the alleged discrimination occur?

Location:

Were there any witnesses to the alleged discrimination? Yes _____ No _____

If yes, please provide witnesses names and contact number.

Describe the incident(s) and include the names and job titles of comparators and how and why they are treated more fairly than you. (Please attach additional pages)

What corrective action do you believe would address your complaint?

Have you filed a previous complaint of alleged discrimination? Yes _____ No _____

If so, briefly describe the incident and when it occurred.

FOR COMPLAINTS BASED ON A HOSTILE WORK ENVIRONMENT

Please respond to each question applicable to your situation. Add additional pages as needed.

Does the hostile behavior you are alleging happen on a frequent basis? If so, explain.

Is the hostile behavior severe? If so, explain.

Is the hostile behavior physically threatening or humiliating? If so, explain. Provide dates, other employees present, if known.

Does the hostile conduct unreasonably interfere with your ability to perform your job duties, or affect a term, condition or privilege of employment? If so, explain.

Do you believe there is a relationship between the hostile behavior and your membership in a protected class? A protected class member is one protected by race, gender, age, disability (mental or physical), etc.

Did your supervisor know or should have known about the hostile behavior? If so, explain. If your supervisor is creating a hostile work place, explain.

Who did you file this complaint with? (Please check all that apply)

Maryland Commission on Civil Rights ____ Equal Employment Opportunity Commission ____

Office of the Statewide Equal Employment Opportunity Coordinator ____ MDH OEOP ____

MEDIATION

Mediation is a process which attempts to have parties in conflict resolve their differences with the assistance of an external mediator from the State of Maryland’s Shared Neutrals Program. Mediation is a voluntary, expeditious and proactive process that encourages dialogue and mutual agreement between parties in conflict. In order for mediation to be successful, both parties must agree to mediate. If either party declines mediation, the complaint will move forward to the investigative phase. Any information discussed during the mediation is confidential. If an agreement is reached, it is put in writing and signed by both parties and the complaint is closed. If an agreement is not reached, then the complaining party may elect to move forward with their complaint.

I would like to have my complaint addressed through the mediation process. YES NO

Complainant’s Signature:

AFFIRMATION

I affirm that I have read the above charge(s) and that it is true to the best of my knowledge, information and belief.

_____________________________________________	_____________________

Signature	Date

Please forward to:

Keneithia J. Taylor, Executive Director/Fair Practices Officer

Office of Equal Opportunity Programs

201 West Preston Street, Room 422-I

Baltimore, Maryland 21201

410-767-6595 (p)

410-333-5337 (f)

keneithia.taylor@maryland.gov

*Please notify the Office of Equal Opportunity Programs of any changes of address and/or telephone number.

NOTICE OF YOUR RIGHT TO FILE A COMPLAINT WITH AN EXTERNAL CIVIL RIGHTS ENFORCEMENT AGENCY

Any employee or applicant for employment, who believes that he or she has been discriminated against, has a right to file a complaint with the State or Federal agencies listed below. A person does not give up this right when he or she files a complaint with the MDH Office of Equal Opportunity Programs. The following State and Federal agencies enforce laws related to discrimination:

Maryland Commission on Civil Rights (MCCR)

6 St. Paul Street, 9th Floor

Baltimore, Maryland 21201

Phone: 410-767-8600

United States Equal Employment Opportunity Commission (EEOC)

31 Hopkins Plaza, Suite 1432

Baltimore, Maryland 21201

Phone: 410-962-3932

STATUTORY TIME PERIODS FOR THE TIMELY FILING OF CHARGES OF DISCRIMINATION (MEASURE FROM THE OCCURRENCE OF DISCRIMINATORY ACTION):

State Fair Practices/EEO Offices- within 30 days after first knowledge or reasonably knowing (SPPA§5-211 (b))

Maryland Commission on Civil Rights (MCCR)- Six (6) months (State Government Article Title 20, Annotated Code of Maryland)

United States Equal Employment Opportunity Commission (EEOC)- 180 calendar days from the day the discrimination took place; 300 calendar days if a state or local agency enforces a law that prohibits employment discrimination on the same basis. See the EEOC’s website for age discrimination filing guidelines (search Timeliness in the EEOC’s search engine)

Confidentiality- Information obtained as part of an investigation conducted under this SPPA§5-214 is confidential within the meaning of Title 10, Subtitle 6 of the State Government Article.

AFFIRMATION

I affirm that I have read the above notice concerning my rights to file a complaint with a local, state, and federal civil rights enforcement agency at any time before or after I file an internal complaint with the MDH Office of Equal Opportunity Programs and am aware of my filing deadlines for those agencies.

_____________________________________________	____________________________

Complainant’s Signature	Date

_____________________________________________	____________________________

Equal Opportunity Director or designee	Date

6

Office of Equal Opportunity Programs (OEOP)

3/2018

FOR USE BY THE MDH OFFICE OF EQUAL OPPORTUNITY PROGRAMS

CASE NO. _____________________________________	BASIS(ES): ___________________________________________

DATE FILED: __________________________________	RESOLUTION: ________________________________________

DO NO WRITE IN THIS SPACE

djjuser

2019-04-25

Srikanth Gadiyaram

DJS