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Date Received by OIG:

Control No.

COMPLAINT OF DISCRIMINATION
PRIVATE EMPLOYMENT
I hereby submit this Complaint to the Office of the Inspector General (OIG) of the City of Houston. I have
read City of Houston Ordinance #2014-530. (A copy of Ordinance #2014-530 may be viewed at
http://www.houstontx.gov/execorders.html.) I have been discriminated against based on: (Please check
appropriate box(es) below:)
Sex Race Color Ethnicity National Origin Age (40+) Military Status Religion
Disability Genetic Information Sexual Orientation Gender Identity Familial Status
Marital Status Pregnancy
If you are claiming retaliation for having filed a prior OIG complaint, please provide: Date of Prior
Complaint ________
The name, address and phone number of the person(s) or business(es) who has or is discriminating are
as follows:
Name __________________________________________________________________________
Address_________________________________________________________________________
Daytime Phone ___________________________________________________________________
Evening Phone____________________________________________________________________

Please provide three dates/times during the business week you are available to have an in-person
interview with an OIG Investigator.
1)
2)
3)
I AFFIRM that all facts and circumstances stated here are true and correct, to the best of my
knowledge. I understand false statements may constitute perjury and/or misconduct.

Signature of Complainant

Printed Name of Complainant

To best contact me, my home mailing address, work and cell/other telephone number(s) are as follows:
Address_________________________________________________________________________
Daytime Phone ___________________________________________________________________
Evening Phone____________________________________________________________________
FORM REVISED BY INSPECTOR GENERAL JUNE 27, 2014