Employment Discrimination Complaint/Intake Questionnaire

Complainant Information

(All fields are required and must have a response)

First Name *

Middle Initial

Last Name *

Home Phone *

Other Phone *

Email *

Address *

City *

State *

Zip *

County *

Date of Birth *

Gender *

Male

Female

National Origin/or Ethnic Group

(Please select one)

State Agency Against Which Complaint is Being Filed

State Agency / Employer *

Division/Dept *

Supervisor Name *

Supervisor Phone *

Address *

City *

State *

Zip *

County *

Complainant / Discriminatory Incident(s) Description

Describe in specific detail, the harm or employer action for which you are filling a complaint (include dates, times, names of witnesses, and what was said and/or happened).

Confirmation of Information Accuracy

I swear to the best of my knowledge and belief that the information contained herein is complete and accurate.

Name *

Date *

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Complaint Process

If you believe that you have been discriminated against at work because of your race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability or genetic information, you can file a complaint.

Learn more about the complaint process

Contact Us

Governor’s Office of Equal Opportunity
100 North Fifteenth Avenue, Suite 301
Phoenix, Arizona 85007

[email protected] (General Mailbox)

Director: Chavon Woods
Interim Program Manager: Michelle Ashley

Stay In Touch

Office of the Governor
1700 W. Washington St.
Phoenix, AZ 85007
602-542- 4331
[email protected]
azgovernor.gov