Nebraska > Federal > Bankruptcy Court > Employment Dispute Resolution Plan
Formal Complaint Under EEO-EDR Plan - Nebraska
| Formal Complaint Under EEO-EDR Plan Form. This is a Nebraska form and can be used in Employment Dispute Resolution Plan Bankruptcy Court Federal . |
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FORMAL COMPLAINT UNDER EEO/EDR PLAN Filed Under the Procedures of the District of Nebraska Equal Employment Opportunity and Employment Dispute Resolution Plan (District of Nebraska EEO/DER Plan). Prior to completing this form, please refer to the District of Nebraska EEO/EDR Plan. Please complete this form legibly. 1. Full Name of Person Filing Complaint 2. Mailing Address 3. Home Phone ( ) Work Phone ( ) 4. If you are a court employee, state the following: Court Unit in which employed Job Title 5. Name and address of the Employing Office against which this complaint is filed (under the terms of the District of Nebraska EEO/EDR Plan, all complaints must be filed against an Employing Office, not an individual): ______________________________________________________________________________6. Identify the Chapter(s) of the District of Nebraska EEO/EDR Plan under which your complaint is being filed. G Chapter II - Equal Employment Opportunity & Anti-Discrimination Rights G Race G Color G Religion G Gender/Sex (includes sexual harassment) G National Origin G Age G Disability G Chapter III - Family and Medical Leave Rights G Chapter IV - Worker Adjustment and Retraining Notification Rights G Chapter V - Employment and Reemployment Rights of Members of the Uniformed Services G Chapter VI - Occupational Safety and Health Protections 1<<<<<<<<<********>>>>>>>>>>>>> 2 G Chapter VII - Polygraph Tests 7. Date(s) of alleged violation: 8. Date on which counseling was requested: Date on which counseling was completed: Date on which mediation was requested: Date on which mediation was concluded: 9. Name of person who served as Counselor on this matter: 10. Name of person who served as Mediator on this matter: 11. Please summarize the actions or occurrences giving rise to your complaint. Explain in what way you believe your rights under the District of Nebraska EEO/EDR Plan were violated. Identify all persons who participated in this matter or who can provide relevant information concerning your complaint. (If there is insufficient space below, you may attach additional pages.) [Please attach a copy of any documents that relate to your complaint, such as an application form, resume,letters, notices of discipline or termination, etc.] 12. What corrective action do you seek from your complaint? 2<<<<<<<<<********>>>>>>>>>>>>> 313. Do you have an attorney or any other person who represents you in this matter? G Yes G No If yes, please provide the following information concerning that person: Name Address Work Phone ( ) Fax ( ) I swear or affirm that the information provided in this complaint is true and correct to the best of myknowledge. Signature Date 3
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