Employee Complaint Form (K-01)

This incident form shall be completed by all persons submitting a formal complaint under the Anne Arundel County Non-Discrimination and Non-Harassment Policy, Employee Relations Manual, Section K-01.

Anne Arundel County is committed to promptly and responsibly investigating all claims of discrimination and all forms of improper harassment under the Non-Discrimination and Non-Harassment Policy. Your cooperation in truthfully completing this form and providing as much accurate information as possible will enable Anne Arundel County to investigate and respond to these matters more quickly and efficiently.

Indicates required field

Your Information

Please select the best description of the person reporting concern:

Home address

Supervisor Information

Offending Party Information

Respondent 1

Respondent 2

Respondent 3

Respondent 4

Incident Information

What is the basis of the alleged discrimination, harassment or retaliation?

Select all that apply
Do you have a witness to the alleged discrimination, harassment or retaliation?
Have you filed this complaint anywhere else?
e.g. with your department, the EEOC, MCCR, etc.

Additional Information

Assistance

Did you have any assistance / did anyone else complete this complaint form on your behalf?

Affirmation

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

Print a copy of this form for your records.