OEAC Employment Discrimination/Hostile Work Environment Complaint Form

This complaint form is to be completed by Maryland State Department of Education employees and applicants for employment, and individuals doing business with the Maryland State Department of Education, 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(s) of employment discrimination.

Work Email

First Name

Last Name

Middle Initial

Home Address

City

State

Zip Code

Phone

Personal Email

Work Phone

Phone

Job Title

Department/Location

Supervisor's Name

Supervisor's Title

Supervisor's Contact Number

Phone

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

*Retaliation

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.

When did the alleged discrimination occur?

Where did the alleged discrimination occur?

(Location)

Were there any witnesses to the alleged discrimination?

Yes

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 upload additional pages, if necessary)

What corrective action do you believe would address your complaint?

Have you filed a previous complaint of alleged discrimination?

Yes

If yes, when? Enter N/A for not applicable.

If yes, briefly describe the incident and when it occurred? Enter N/A for not applicable.

Upload additional pages and supporting documentation here.

This may include additional text related to your complaint and/or evidence to support your allegations.

Drop your files here

FOR COMPLAINTS BASED ON HOSTILE WORK ENVIRONMENT

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

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

Is the behavior severe? If so, please explain.

Is the hostile behavior physically threatening or humiliating? If so, please, 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, please 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), religion, sexual orientation, gender identity and expression, military status, etc.

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

Alternative Dispute Resolution

Executive Order 01.01.2007.16, Code of Fair Employment Practices (II)(C)(1) allows provisions for resolving complaints informally, whenever possible. Alternative Dispute Resolution (ADR) is a process by which the parties in conflict resolve their differences with the assistance of the Director, Office of Equity Assurance and Compliance, or their designee. ADR is an expeditious and proactive process that encourages dialog and a mutual agreement between the parties in conflict. If an agreement is reached, it is put in writing. Both parties sign the agreement and the matter is closed. If ADR is unsuccessful, the complaining party may elect to move forward with the complaint.

A Complainant has a right to decline this process. The Office of Equity Assurance and Compliance will procced with a fair, impartial and thorough internal investigative process in accordance with state and federal regulations.

I have reviewed the information about ADR and would like my complaint addressed through the ADR process.

Yes

AFFIRMATION

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

* Please notify the Office of Equity Assurance and Compliance of any changes of address and/or telephone number.

The above charge(s)is true to the best of my knowledge, information and belief.

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 MSDE Office of Equity Assurance and Compliance. 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: 1-800-669-4000

A program participant may with the following agencies within 180 days of alleged violation:

Maryland Commission on Civil Rights (MCCR)

6 St. Paul Street, 9th Floor Baltimore, Maryland 21201

Phone: 410-767-8600

U.S. Department of Education Office for Civil Rights

400 Maryland Avenue, SW

Washington, DC 20202-1100

1-800-421-3481; Fax: 202-245-6840; TDD: 877-521-2172

Email: OCR@ed.gov

U.S. Department of Justice Civil Rights Division

950 Pennsylvania Ave., NW

Washington, DC 20530

1-877-292-3804 or 202-514-4092; Fax: 202-514-8337; TDD: 202-353-3926

Email: education@usdoj.gov

Complaints may be filed with any one of the external agencies and OEAC simultaneously.

STATUTORY TIME PERIODS FOR THE TIMELY FILING OF CHARGES OF DISCRIMINATION (MEASURE FROM THE OCCURREN

1. State Fair Practices/EEO Offices- within one year after first knowledge or reasonably knowing (SPPA§5-211(b)), A complaint filed under SPP Title 5-211 (A) (2) alleging harassment in violation of § 20–606(a)(5) of the State Government Article must be filed within two years after the alleged violation that is the basis for the complaint.

2. Maryland Commission on Civil Rights (MCCR)- within 300 days for all other complaints and Two (2) years for harassment complaints only (State Government Article Title 20, Annotated Code of Maryland). 180 days for public accommodations complaints.

3. United States Equal Employment Opportunity Commission (EEOC)- within 300 days from the day the discrimination took place; See the EEOC’s website for age discrimination filing guidelines (search Timeliness in the EEOC’s search engine)

4. United States Department of Education or the US Department of Justice within 180 days of alleged date of discrimination.

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

By checking the box below, 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 MSDE Office of Equity Assurance and Compliance and am aware of my filing deadlines for those agencies.

I have read the above notice concerning my rights to file externally.

By typing my name below, I declare under the penalty of perjury that the above information is true and correct.

Today's date is:

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