Michigan Department of Environmental Quality
Grievance Submittal Form
Nondiscrimination in Michigan Department of Environmental Quality (MDEQ) Programs Policy and Procedure Number 09-024
SECTION I. COMPLAINANT INFORMATION
FIRST NAME: EMAIL ADDRESS: TELEPHONE NUMBER: MAILING ADDRESS: CITY:
LAST NAME:
STATE:
ZIP:
SECTION II. INCIDENT INFORMATION
DATE OF INCIDENT:
DATE OF GRIEVANCE SUBMISSION:
LOCATION OF INCIDENT (Include street crossing, street number, street, city, state, ZIP)
Please identify the parties harmed or potentially harmed by the alleged discrimination. Use additional pages if necessary.
List the state and/or federal statute(s) or regulation(s) that the MDEQ allegedly violated and detail with specificity the action(s) or inaction(s) by the MDEQ that support the alleged violation. Use additional pages if necessary.
Describe with specificity the action(s) or inaction(s) allegedly resulted in discrimination. Use additional pages if necessary.
www.michigan.gov/deq
Sierra Club v. EPA 18cv3472 NDCA
800-662-9278
Tier 10
EQP____ May 2018
ED 002061 00174678-00001
GRIEVANCE SUBMITTAL FORM Nondiscrimination in MDEQ Programs - Policy and Procedure Number 09-024
SECTION III. CERTIFICATION
I certify under penalty of law that I am familiar with the information submitted and that, based on my experience and inquiry, I believe the submitted information is true, accurate, and complete.
Signature Print Name
Date
Submit this form with any additional pages to: Nondiscrimination Compliance Coordinator
Michigan Department of Environmental Quality P.O. Box 30473
Lansing, Ml 48909-7973 or by email to:
DEQ-NondiscriminationCC@michigan.gov
It is the policy of the MDEQ not to discriminate on the basis of race, sex, religion, age, national origin, color, marital status, handicap, disability, political beliefs, height, weight, genetic information, or sexual orientation in the administration of any of its programs or activities, as required by applicable laws and regulations.
To ensure individuals can invoke these grievance procedures without fear of reprisal, MDEQ explicitly prohibits retaliation against any individual for any purpose, including for the purpose of interfering with any right or privilege guaranteed under any state or federal statutes or regulations because that individual has filed a complaint or has testified, assisted, or participated in any way in an investigation, proceeding, or hearing of any kind or has opposed any practice made unlawful under any state or federal statutes or regulations. Prohibited retaliatory acts include intimidation, threats, coercion, or discrimination against any such individual or group. Any concern regarding retaliation should be reported to the NCC.
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Sierra Club v. EPA 18cv3472 NDCA
Tier 10
ED 002061 00174678-00002