SRBC Non-Discrimination Complaint Form

Home Non-Discrimination Complaint Form

Non-discrimination Complaint Form

Please use this form to enter details of a complaint.

Person Alleging Discrimination

First Name:

Last Name:

Address:

City:

State:

Zip:

Phone #:

Email address:

Person Reporting the Complaint (if different than person alleging discrimination)

First Name:

Last Name:

Address:

City:

State:

Zip:

Phone #:

Email address:

Date and Time of Incident:

Complaint Description: Maximum 2000 characters.

Thank you for submitting a non-discrimination complaint to SRBC.

An error occurred while submitting the complaint. For help, please contact:

Deepali Carlson, Human Resources Manager, SRBC
Telephone: (717) 238-0423
E-mail: [email protected]

Complaints of discrimination made to SRBC, the US Environmental Protection Agency Office of External Civil Rights Compliance (US EPA OECRC), the US Equal Employment Opportunity Commission (EEOC), or the Pennsylvania Human Relations Commission (PHRC) must ordinarily be filed within 180 days of the last act of alleged discrimination. However, extensions of these deadlines may be permitted under certain circumstances. You should contact SRBC or the appropriate agency directly for more information.