EEO Complaint Form

Please be advised that anonymous complaints limit the investigation’s scope due to their inability to communicate with all relevant parties.

Contact Information

Preferred Contact Method: Phone Postal Mail E-Mail

Name:

Payroll Job Title:

Unit/Dept:

Shift/Schedule Card:

Warden/Supervisor Name:

Date of Birth:

Phone: () -

Mailing Address:

City:

State:

ZIP:

E-mail:

Respondent Information (person subject to complaint)

Respondent Name:

Respondent Unit/Dept:

Respondent Payroll Job Title:

Nature of Complaint more

I believe I experienced discrimination, harassment, or retaliation because of: (select at least one)

Age

Disability

Genetic Information

National Origin

Pregnancy

Race/Color

Religion

Sex

Sexual Harassment

Filing an EEO Complaint

Participating in an EEO Investigation

Requesting an Accommodation

None

Statement

Date of Incident

Begin Date (optional)

End Date (if applicable)

Location:

Witness(es):

Was this reported to a supervisor? Yes No

Supervisor's Name:

Statement

Disclaimer

I understand that in addition to any action the TDCJ may take in this matter, I may have filing rights with the Texas Workforce Commission, Civil Rights Division (TWC-CRD) and the U.S. Equal Employment Opportunity Commission (EEOC). I also understand that I may contact the Office of the Inspector General (OIG) if I elect to pursue criminal charges relating to this complaint.

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