Worcester Regional Transit Authority
EEO Complaint Form
The Worcester Regional Transit Authority (WRTA) is committed to equal employment opportunity (EEO) and ensures that no employee, applicant or potential applicant is discriminated against on the basis of race,color, creed, national origin, sex, age, or disability.
Instructions: If you believe you have been discriminated against on the basis of race, color, creed, national origin, sex, age, or disability and would like to submit an EEO Complaint to the WRTA, please complete this form. The information requested is necessary in order to processyour complaint, which must be submitted within 180 days from the date the alleged discriminationoccurred.
If you need assistance with completing this form, please contact the EEO Officer at 1-508-453-3408.
Return your completed form to:Worcester Regional Transit Authority
Attention: EEO Officer
42 Quinsigamond Ave.
Worcester, MA 01610
Check One: You are An applicant ______Employee______
1. Name (Complainant) ______
2. Address ______
(Street including Apt #)
______
(City) State) (Zip Code)
3. Telephone Number (Home) ______(Cell) ______
4. Name of person discriminated against
(If someone other than the complainant) ______
5. Address ______
(Street including Apt #)
______(City) (State) (Zip Code)
6. Telephone Number (Home) ______(Cell) ______
7. Which of the following best describes the reason you believe the discrimination took place?
(Check all that apply) Race___ Color___ National Origin (Limited English Proficiency)____
Creed ______Sex______Age______Disability______
8. Date, time and location (if applicable) of the incident. ______
______
9. Please explain the nature of your complaint and how you feel you were discriminated against.
Please use the back of this form if additional space is required.
______
______
10.Why do you believe these events occurred?
______
______
11. Please explain how you feel that others were treated differently than you.
______
______
______
12. Name(s) and title(s) of the person(s) you believe discriminated against you (if known).
______
______
13. Other information you feel may be relevant to the investigation of your complaint?
______
______
14. How can this complaint be resolved to your satisfaction?
______
______
15. Did anyone else witness the incident?Yes______No______
List all witnesses (use a separate sheet if necessary):
Witness #1 Name ______Phone # ______
Address ______
(Street) (City) (State) (Zip Code)
Witness #2 Name ______Phone # ______
Address ______
(Street) (City) (State) (Zip Code)
16. Please list any other person/s we may contact for additional information or to support/clarify yourcomplaint.
Name ______Phone # ______
Address ______
(Street) (City) (State) (Zip Code)
17. Have you filed a complaint about this incident with any other federal, state, or local agency, or withany federal or state court? Yes_____ No_____ If yes, when? __/___/____
If yes, which agency (check all that apply)?
Federal Agency____ Federal Court_____ Federal Transit Administration______
State Agency______State Court______Local Agency: Other______
(Please specify)
18. If you filed with an agency and/or court, please provide the following:
Agency and/or court name: ______
Contact’s Name: ______
Address ______
(Street) (City) (State) (Zip Code)
Phone Number: ______
Your signature below indicates that the information you provided in this EEO Complaint Form is true andcorrect to the best of your knowledge, information and belief.
______
Your Signature (Complainant) Date of filing
Internal Use Only (To be completed by WRTA EEO Officer)
Accepted for formal investigation on ____/_____/______
Action taken (To be completed by WRTA EEO Officer)
______
______
______
Rejected on: ____/_____/______Reason: ______
______
Signature Date
WRTA EEO Officer
______
Signature Date
Central Mass Transit Management, Inc.
General Manager
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