County of Dane CUSTOMER COMPLAINT FORM
If you need assistance in completing this form, please contact the Dane County Office of Equal Opportunity at (608) 266-5623. COMPLAINANT INFORMATION: Name: Address: City, State, Zip : Home Phone: Name of Department/Division: Work Phone:
ISSUES INVOLVED (Check appropriate box(es)
1 Discrimination 2 Treatment 3 Access to Services 4 Harassment 5 Other (Specify)
TYPE OF COMPLAINT (Check appropriate box(es)
6 Race 7 Color 8 Gender 9 Age 10 Religion 11 National Origin 12 Disability 13 Ancestry 14 Marital Status 15 Physical Appearance 16 Sexual Orientation 17 Sexual Harassment 18 Other If Other, please identify :
Describe your complaint. State all facts, including date of occurrence and time, place of incident, names of others involved, witnesses (if any), and the action you wish the Department to take. Use additional paper if necessary. 1. What happened? (Include all important times, dates, witnesses and events)
2.
What actions have you taken up to this point?
3.
What actions do you wish to help resolve your complaint?
Signature of Complainant:
Complaints are protected from retaliation by state law
Date: