Nebraska Department of Transportation

Employee Complaint Form: Violation of Equal Employment Rights

The following prohibited conduct may be reported utilizing this form**:

-Discrimination, harassment, and/or the creation of a hostile work environment based on race, color, sex (including pregnancy), religion, national origin, age, disability, marital status, and genetic information, are prohibited at the Nebraska Department of Transportation.

-Discrimination based on military status or service requirements is also prohibited.

-Retaliation against an employee for complaining about or reporting discrimination, harassment and/or creation of a hostile work environment based on the aforementioned protected criteria is also prohibited.

**Employees should report all other types of inappropriate behavior through their chain of command.

Employee Name:	Position Title:
Home Address:	Division/District::
Supervisor’s Name:
Work Phone No.:	Phone No.:
Home Phone No.:	May the Supervisor be contacted?	Yes No
Type of Complaint: Discrimination or Harassment based on: Race Color Sex (incl. pregnancy) Religion National Origin Age Disability Retaliation GINA Marital status Military Status
Date and place of alleged prohibited conduct. Please include both the earliest date prohibited conduct occurred, as well as the most recent date of harassment.
Explain as briefly and clearly as possible what happened and how you were discriminated against or harassed. Indicate who was involved. Be sure to include how other persons were treated differently than you. Also, attach any written material pertaining to your complaint (attach additional pages, if necessary).
Names and contact information of persons (witnesses, others) whom we may contact for additional information to investigate your complaint.

Please sign and date this complaint form below. You may attach any written materials or other supporting information that you believe is relevant to the complaint. Attachments: Yes No

*Please select the type of complaint you wish to file: Informal or Formal

(See explanation of informal vs formal, page 2)

SUBMIT COMPLETED FORM TO:

Nebraska Department of Transportation

Human Resources Administrator OR Civil Rights Coordinator

1500 Nebraska Parkway

PO Box 94759

Lincoln, NE 68509

Employee Signature:	Date:
Complaint Received By:	Date:

NDOT Form 305, June 2023

INFORMAL	FORMAL

*Decision issued within 30 days of receipt of the initial complaint	*Decision issued within 60 days of initial complaint, UNLESS received on appeal from the INFORMAL level, in which case decision will be issued within 30 days of receipt of the appeal in the CRS/EEO office. (Appeals: Begin at step 3)
1. *HR and Civil Rights Section/EEO (CRS) investigates together	1. *HR and Civil Rights Section/EEO (CRS) investigates together
2. HR issues written report detailing investigation. Copy goes to CRS.	2. HR and CRS issue written report detailing investigation. Copy goes to HR and CRS.
3. HR issues formal written Determination/Finding: “Possible Discrimination”–or-“Non-discrimination” -Copy of Determination to CRS and to the Complainant.	3. CRS/EEO schedules formal meeting before the Civil Rights Section with Complainant, HR investigator, EEO officer, and other interested parties as determined by the EEO officer (witnesses may be called at the formal meeting)
4. HR meet with Complainant to discuss potential outcomes, including possibly conducting a meeting between Complainant and the offending party to develop a resolution plan (based completely on request of complainant) (copy of plan, if developed to CRS/EEO) If determined the Complaint is not an EEO issue, HR will complete the investigation outside of this EEO process.	4. After formal meeting, CRS may request that HR/EEO complete additional investigation as needed after the step 3 formal meeting.
5. Complainant advised of right to appeal the HR Determination to the Civil Rights Section Head and utilize the FORMAL process. -Appeal must be made in writing to CRS within 5 work days from HR Determination. *If appealed, go to step 3 of FORMAL process.	5. CRS issues formal written Determination: “Possible Discrimination”–or-“Non-discrimination” -Determination provided to the **Complainant, HR and the Director/Deputy Director, with a copy of any additional investigatory report to HR and the Director/Deputy
6. If finding of discrimination, HR makes referral to supervisor of offending party for potential disciplinary action (copy of referral to CRS/EEO)	6. If finding of discrimination, HR advised to make referral to supervisor of offending party for potential disciplinary action
7. HR advised to offer potential outcomes in event of finding of discrimination, including possibly conducting a meeting between Complainant and the offending party to develop a resolution plan (based completely on request of complainant)
*If allegation of discrimination is against an individual assigned to the HR division, investigation is performed by the CRS/EEO; if made against CRS/EEO personnel, investigation is performed by HR.	* If allegation of discrimination is against an individual assigned to the HR division, investigation is performed by the CRS/EEO; if made against CRS/EEO personnel, investigation is performed by HR.