STATE OF NEVADA by X7uYuEq

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									                                              STATE OF NEVADA




             Intake Report of Harassment or Discrimination
          (To be completed by agency coordinator or harassment/discrimination unit investigator.)

SECTION I – COMPLAINANT INFORMATION:
1. Complainant Name                                         2. Title


3. Immediate Supervisor


4. Department                                               5. Division                        6. Section/Unit


7. Work Location                                            8. Work Phone                      9. Home Phone



SECTION II – COMPLAINANT INTERVIEW:                            (Attach original documentation of statements, materials or
evidence.)

Make complainant aware that complaints of harassment or discrimination will be investigated.
Check which type of Harassment or Discrimination complaint is alleging.

Sexual Harassment                       Sex Discrimination                         Racial Discrimination
Age Discrimination                      Religious Discrimination                   National Origin Discrimination
Disability Discrimination               Sexual Orientation                         Pregnancy Discrimination
Color Discrimination



*Hostile Work Environment                 *Please note, Hostile Work Environment and Retaliation must be based
*Retaliation                               on one of the protected groups listed above. Check if appropriate.
1. Describe the harassment/discrimination incident(s) including the dates, times and locations of the incidents.




2. Who or what was responsible for the harassment/discrimination incident(s)?
            Intake Report of Harassment or Discrimination
3. Identify any witnesses to the harassment/discrimination incident(s). Please provide name(s), address(es), and phone
   number(s).




SECTION III – ACCUSED INFORMATION:

1. Accused Name                                             2. Title


3. Relationship to the Complainant (i.e. supervisor, co-worker, subordinate, etc.)


4. Department                                               5. Division                     6. Section/Unit


7. Work Location                                            8. Work Phone                   9. Home Phone


10. Comments by person completing this form.




11. Has the complainant been asked to either file a complaint online in NEATS or to complete the NPD-30 Sexual Harassment
or Discrimination Complaint form?
        Yes        No If not please explain.


11. Name of person completing this form and phone number.        12. Date and time form completed.


 ORIGINAL TO INVESTIGATOR                     COPY TO AGENCY DIRECTOR OR AGENCY PERSONNEL LIAISON

                                                                                                              NPD-31 5/11/06

								
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