Pers 497 Form PDF Details

In the realm of employment within the Texas Department of Criminal Justice (TDCJ), ensuring a fair and respectful workplace is paramount. The PERS 497 form plays a critical role in this endeavor, providing a structured means for employees to report instances of discrimination and misconduct. This form allows individuals to formally voice their concerns regarding a wide range of discriminatory practices, including issues related to race, color, national origin, gender, sexual harassment, age, disability, and religion, among others. By requiring detailed information about the complainant, the respondent, and the nature of the complaint, including dates, specifics of the discriminatory event, and potential witnesses, the PERS 497 form ensures that complaints are thoroughly documented. This procedure not only facilitates the investigation process by the TDCJ but also informs complainants of their right to file with external bodies, such as the Texas Workforce Commission, Civil Rights Division (TWC-CRD) and the U.S. Equal Employment Opportunity Commission (EEOC), for further recourse. Additionally, it underscores the complainants' entitlement to be informed about the information collected on them by the TDCJ and to seek correction of any inaccuracies. Thus, the PERS 497 form stands as a cornerstone in the efforts to uphold equality and justice within the Texas Department of Criminal Justice's working environment.

QuestionAnswer
Form NamePers 497 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesComplainants, foregoing, Texas, OIG

Form Preview Example

Texas Department of Criminal Justice

EEO COMPLAINT FORM

Complainant Information (Person Complaining)

Name:

Last

First

MI

Title:

Work Shift:

Home Mailing

Address:

Street Address

City

State

Zip

Payee ID:

Unit or Dept:

Schedule Card:

Home or Cell

Phone #:

(Area Code)

 

Name of Warden or Department Head:

 

 

 

 

 

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Respondent Information (Person Complained Against)

 

 

 

 

 

 

 

 

Name:

 

 

 

Title:

 

 

 

 

 

Unit or Dept:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date(s) of Discriminatory Event:

 

 

Earliest:

 

 

 

 

 

 

 

Latest:

 

 

 

Are you complaining about:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Check)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Slurs or Hostile Epithets?

Yes

 

No

If yes, explain:

 

 

 

 

 

 

 

 

 

Color Discrimination?

Yes

 

No

If yes, identify your color:

 

 

 

 

 

 

 

 

 

Race Discrimination?

Yes

 

No

If yes, identify your race:

 

 

 

 

 

 

 

 

 

National Origin Discrimination?

Yes

 

No

If yes, identify your national origin:

 

 

 

 

 

 

 

 

Gender Discrimination?

Yes

 

No

If yes, identify your gender:

Male

Female

 

Discourteous Conduct of a

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sexual Nature?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sexual Harassment?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age Discrimination?

Yes

 

No

If yes, identify your date of birth:

 

 

 

 

 

 

 

 

 

Disability Discrimination?

Yes

 

No

If yes, identify your disability:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EEO Retaliation?

Yes

 

No

If yes, retaliation for what EEO activities?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Genetic Information?

Yes

 

No

If yes, specify:

 

 

 

 

 

 

 

 

 

Religion?

Yes

 

No

If yes, identify your religious belief:

 

 

 

 

 

 

 

 

Other?

Yes

 

No

If yes, specify:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complainant’s Initials: _________

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM/DD/YYYY

 

 

PERS 497 (09/21)

STATEMENT

(Attach additional pages as needed. Number, sign, and date each additional page.)

1. Include specific details such as “who, what, when, and where” for each alleged event of your complaint.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

2.List name(s) of all known witnesses and provide, in your own words, a summary of what the witness(es) may testify about the alleged event.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

3. List name(s) of all individuals to whom you reported the alleged event and the date(s) you reported the alleged event.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

The foregoing statement contains all of my complaint(s), all names of witnesses, and all names of individuals to whom I reported the alleged event. This complaint includes this two-page form and ______ additional pages attached,

numbered, signed, and dated. I understand that in addition to any action the TDCJ may take in this matter, I may have filing rights with the Texas Workforce Commission, Civil Rights Division (TWC-CRD) and the U.S. Equal Employment Opportunity Commission (EEOC). I also understand that I may contact the Office of the Inspector General (OIG) if I elect to pursue criminal charges relating to this complaint.

Complainant Signature: ___________________________________

Date: _____________________

 

MM/DD/YYYY

Note to Employee: With few exceptions, you are entitled upon request: (1) to be informed about the information the TDCJ collects about you; and (2) under Texas Government Code §§ 552.021 and 552.023, to receive and review the collected information. Under Texas Government Code § 559.004, you are also entitled to request, in accordance with TDCJ procedures, that incorrect information the TDCJ has collected about you be corrected.

PERS 497 (09/21)

How to Edit Pers 497 Form Online for Free

Our PDF editor makes submitting files stress-free. It is quite convenient to enhance the [FORMNAME] form. Stick to the next actions if you would like do it:

Step 1: Click on the "Get Form Here" button.

Step 2: Now you are on the file editing page. You may enhance and add content to the form, highlight specified content, cross or check certain words, include images, insert a signature on it, get rid of needless fields, or take them out altogether.

The next few segments are what you will have to fill out to have the prepared PDF document.

twc spaces to complete

You need to type in the required information in the Slurs or Hostile Epithets, Color Discrimination, Race Discrimination, Check, Yes, Yes, Yes, If yes explain, If yes identify your color, If yes identify your race, National Origin Discrimination, Yes, If yes identify your national, Gender Discrimination, and Yes field.

step 2 to filling out twc

The program will require you to insert particular relevant details to conveniently complete the section Religion, Other, Yes, Yes, If yes identify your religious, If yes specify, Complainants Initials, Date, MMDDYYYY, and PERS.

stage 3 to entering details in twc

It's essential to describe the rights and obligations of both sides in box Include specific details such as, List names of all known witnesses, about the alleged event, and List names of all individuals to.

Include specific details such as, List names of all known witnesses, about the alleged event, and List names of all individuals to in twc

Terminate by reading the following sections and preparing them accordingly: List names of all individuals to, The foregoing statement contains, Complainant Signature, Date, MMDDYYYY, and Note to Employee With few.

twc List names of all individuals to, The foregoing statement contains, Complainant Signature, Date, MMDDYYYY, and Note to Employee With few blanks to fill

Step 3: Choose the Done button to confirm that your finished form is available to be transferred to any electronic device you pick out or sent to an email you specify.

Step 4: Come up with a duplicate of each file. It can save you time and enable you to avoid concerns in the long run. Keep in mind, the information you have isn't going to be shared or monitored by us.

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