Online Complaint System

1 Begin Complaint

2 Reporting Party

3 Complaining Party (ies)

4 Involved Party (ies)

5 Witness (es)

6 Nature Of Complaint

7 Voluntary EEO

8 Confirmation

Reporting Party Information
Person completing this form
Employee Number*
Enter 'e' or 'c' followed by employee/contractor number. If you aren't a county employee or contractor enter 'n000000'.
Title
Name*
First MI Last
Work Phone*
Mobile Phone*
Work Extension
Work Hours
RDO
Reporting Party's Unit Of Assignment
Reporting Party's Department*
Other Department*
Reporting Party Email Address*

Enter your email address. (For Example, ________@______.gov, com, net, etc.) If you do not have an email address, just enter any text in this format to proceed.
Reporting Party's Department Head
First MI Last
Reporting Party's Work Address
Street Address Address Line 2 City State Zip Code
Reporting Party's Immediate Supervisor
First MI Last
Reporting Party's Immediate Supervisor's Phone Number
Same as reporting party
- Same as reporting party
Name of person completing this form (if different from above)*
First MI Last
Did the complainant notify a supervisor of this complaint prior to now?
- Yes
- No
- Don't Know
Name of supervisor who was notified*
First MI Last
When was supervisor notified*
Time*

: HH

MM
How was supervisor notified*
Supervisor/Manager

To be completed by Supervisors/Managers only!
Date and Time notified of potential violation/observation was made:
Date*
Time*

: HH

MM
How did you become aware of the potential violation (explain in detail)*
Supervisor's Actions (if any) (explain in detail)*
Did you ascertain whether complainant(s) are in need of:
:•
Medical Attention*
Response*
Protection*
Response*
Separation from Involved Party*
Response*
Other*
Response
Did you advise the complainant(s) that they:
May seek confidential counseling or assistance from County's Employee Assistance Program (EAP) at (213) 738-4200*
May contact the County Intake Specialist Unit directly at (855) 999-2367, or via email at ceop@bos.lacounty.gov*
* Items marked with an asterisk (*) are required

Alleged Complainants

Complainants

Name	Title	Unit of Assignment	Work Phone	Mobile Phone	Work Hours	RDO
							Edit Delete
There are no Complainants.

The COMPLAINANT is the person who was subjected (directly or indirectly) to the alleged prohibited conduct as provided in the policy. Please note that this can be more than one person.

* Items marked with an asterisk (*) are required

Alleged Involved Parties

Parties

Employee Name	Title	Unit Of Assignment	Work Phone	Mobile Phone	Work Hours	RDO
							Edit Delete
There are no Parties.

The ALLEGED INVOLVED PARTIES are the people who are alleged to have engaged in the prohibited conduct as provided in the policy. Please note that this can be more than one person.

* Items marked with an asterisk (*) are required

Alleged Witnesses

Witnesses

Employee Name	Title	Unit Of Assignment	Work Phone	Mobile Phone	Work Hours	RDO
							Edit Delete
There are no Witnesses.

Witnesses are the people who saw or heard the alleged prohibited conduct as provided in the policy. Please note that this can be more than one person.

* Items marked with an asterisk (*) are required

Nature of the Complaint
Date of alleged incident*
Nature of the complaint*
Be as detailed as possible, include all incidents and evidence.
Why does the Complainant believe this treatment is occurring?*
* Items marked with an asterisk (*) are required

Voluntary EEO Statistical Information Submission

Optional: Please provide the following information below for statistical purposes:
Race/Ethnicity
Race/Ethnicity of person completing this form.
Gender
Gender of person completing this form.
- Male
- Female
- Prefer Not to Answer
DOB
Date of birth of person completing this form.

Submission Confirmation and Attachment
Supporting Document
[1 PDF File Format / 10MB Max]
Accepted file types: pdf.
Email Confirmation
- Yes, I would like to get an e-mail confirmation
Email Address*
CAPTCHA
Security Check*
- I'm not a robot
Note: After you select 'Submit' you will not be able to go back and edit the form. Please contact the County Intake Specialist Unit to make changes to this form
Reference Number
Phone
This field is for validation purposes and should be left unchanged.

Online Complaint System

Begin Complaint

Acknowledgement

Reporting Party Information

Person completing this form

Supervisor/Manager

:•

Alleged Complainants

Alleged Involved Parties

Alleged Witnesses

Nature of the Complaint

Voluntary EEO Statistical Information Submission

Submission Confirmation and Attachment

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