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If you have suffered an adverse employment action (such as termination, demotion, failure to promote, suspension, reduction in hours or reduction in pay), please state the reason given by your employer for the adverse action:

If you have suffered an adverse action as described above, please state what you believe to be the reason for the adverse action (such as being in a protected class based on race, sex, national origin, age, disability, religion or engaging in protected activity such as whistleblowing, using medical leave or filing a worker's compensation claim) and identify any evidence you believe supports your claim (such as discriminatory comments or being treated differently than other employees):

If you believe you have been subjected to sexual harassment or subjected to a hostile work environment based upon your being part of a protected class (such as sex, race, age, religion, disability or national origin), please describe in detail the conduct to which you have been subjected, including any relevant dates:

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