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Name* (First, Middle Initial, and Last)<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n\t\n\t\t
Home Phone*<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n\n\t
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Business Phone<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n\t\n\t\t
Email<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n\n\t
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Address* <\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\nState Agency you believe has discriminated or retaliated\n<\/h3>\n\n\t
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Agency*<\/label>—Please choose an option—<\/option> Apple Commission<\/option> Arts Commission<\/option> Athletic Commission<\/option> Barley Commission<\/option> Bean Commission<\/option> Board of Tax Appeals<\/option> Boise State University<\/option> Code Commission<\/option> Commission for the Blind & Visually Impaired<\/option> Commission of Pardons and Parole<\/option> Commission on Aging<\/option> Commission on Hispanic Affairs<\/option> Correctional Industries<\/option> Council for Deaf and Hard of Hearing<\/option> Council on Developmental Disabilities<\/option> Council on Domestic Violence<\/option> Dairy Commission<\/option> Department of Administration<\/option> Department of Agriculture<\/option> Department of Correction<\/option> Department of Education<\/option> Department of Environmental Quality<\/option> Department of Finance<\/option> Department of Fish and Game<\/option> Department of Health and Welfare<\/option> Department of Insurance<\/option> Department of Lands<\/option> Department of Parks and Recreation<\/option> Department of Water Resources<\/option> Division of Financial Management<\/option> Division of Human Resources<\/option> Division of Military<\/option> Division of Occupational & Professional Licenses<\/option> Division of Veterans Services<\/option> Division of Vocational Rehabilitation<\/option> Educational Services for the Deaf and the Blind<\/option> Endowment Fund Investment Board<\/option> Forest Products Commission<\/option> Grape Growers & Wine Producers Commission<\/option> House of Representatives<\/option> Idaho Board of Scaling Practices<\/option> Idaho Career and Technical Education<\/option> Idaho Children\u2019s Trust Fund<\/option> Idaho Commission for Libraries<\/option> Idaho Department of Commerce<\/option> Idaho Department of Juvenile Corrections<\/option> Idaho Department of Labor<\/option> Idaho Department of Transportation<\/option> Idaho Industrial Commission<\/option> Idaho Public Safety Communications<\/option> Idaho Public Television<\/option> Idaho Rural Partnership<\/option> Idaho Soil and Water Conservation Commission<\/option> Idaho State Historical Society<\/option> Idaho State Liquor Division<\/option> Idaho State Police<\/option> Idaho State University<\/option> Idaho Supreme Court<\/option> Idaho Tax Commission<\/option> Idaho Workforce Development Council<\/option> Information Technology Services<\/option> Judicial<\/option> Lava Hot Springs Foundation<\/option> Legislative Services Office<\/option> Lewis-Clark State College<\/option> Lottery Commission<\/option> Northwest Power and Conservation Council<\/option> Office of Drug Policy<\/option> Office of Energy and Mineral Resources<\/option> Office of Performance Evaluations<\/option> Office of Secretary of State<\/option> Office of Species Conservation<\/option> Office of the Attorney General<\/option> Office of the Governor<\/option> Office of the Lieutenant Governor<\/option> Office of the State Board of Education<\/option> Office of the State Controller<\/option> Office of the State Treasurer<\/option> Pea and Lentil Commission<\/option> Potato Commission<\/option> Public Employee Retirement System of Idaho<\/option> Public Health District 1<\/option> Public Health District 2<\/option> Public Health District 3<\/option> Public Health District 4<\/option> Public Health District 5<\/option> Public Health District 6<\/option> Public Health District 7<\/option> Public Utilities Commission<\/option> Rangeland Resource Commission<\/option> Senate<\/option> State Appellate Public Defender<\/option> State Independent Living Council<\/option> State Insurance Fund<\/option> State Public Defense Commission<\/option> STEM<\/option> Superintendent of Public Instruction<\/option> University of Idaho<\/option> Wheat Commission<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n\t\n\t\t
Department (if known)<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n\n\t
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Agency Location<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n \nComplaint Information\n<\/h3>\n\n\t
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Is the complaint in connection to your participation in a WIOA program?<\/label>—Please choose an option—<\/option> Yes<\/option> No<\/option> I don't know<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n\n\t
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Have you contacted the agency regarding this complaint?<\/label>Yes<\/span><\/label><\/span>No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n\n\t
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If yes, date of contact<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n\t\n\t\t
Who did you speak with?<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n\n\t
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Basis for complaint<\/label>—Please choose an option—<\/option> Race<\/option> Color<\/option> Religion<\/option> Sex<\/option> National Origin<\/option> Age<\/option> Disability<\/option> Political Affiliation<\/option> Belief<\/option> Citizenship<\/option> Participation in WIOA Title I Program or Activity<\/option> Multiple<\/option> Other<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n\n\t
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Date of Incident*<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n\t\n\t\t
Where did the incident occur?<\/label> <\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n\n\t
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Describe the details of the incident:*<\/label>