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The Pers 497 form is a vital document used by the Texas Department of Criminal Justice for filing complaints regarding employment discrimination. It provides a structured way for individuals to report grievances related to various forms of discrimination, including race, gender, age, and disability, among others. Complainants are asked to provide detailed information about the alleged discriminatory events, including specific dates, names, and circumstances that clarify the situation. The form not only captures the complainant’s personal information but also requires them to disclose details about the respondent and any witnesses who may support their claims. By outlining the nature of the complaint, such as hostile conduct or retaliation for prior complaints, the form helps the Texas Workforce Commission and the U.S. Equal Employment Opportunity Commission in assessing the complaint. Completing the Pers 497 is an essential step for individuals seeking justice in the workplace, as it opens pathways for further investigation and potential resolution of the issues raised. Furthermore, it serves as a reminder of the rights employees have in seeking information about their cases and ensuring accuracy in reporting.

Pers 497 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)

Get Pers 497 PDF Form

Form Characteristics

Fact Name Description
Governing Body This form is governed by the Texas Department of Criminal Justice (TDCJ).
Purpose The PERS 497 form is used for filing an Equal Employment Opportunity (EEO) complaint.
Complainant Details It collects comprehensive information about the complainant, including name, title, and contact details.
Respondent Details Information about the respondent, including their name and role, is required.
Types of Discrimination The form addresses various discrimination types such as race, gender, age, and disability.
Witness Information The complainant must list known witnesses along with summaries of their potential testimonies.
Reporting Process Complainants need to document individuals they reported the event to, including dates.
Additional Rights Complainants can file rights with agencies like the Texas Workforce Commission or the EEOC.

Guidelines on Utilizing Pers 497

Filling out the Pers 497 form is a crucial step for addressing a complaint relating to EEO issues within the Texas Department of Criminal Justice. Ensure that you approach each section with clarity and accuracy. Following the steps below will help you complete the form correctly.

  1. Provide Complainant Information: Fill in your full name (last, first, and middle initial), title, work shift, and your home mailing address including street, city, state, and zip code. Add your Payee ID, unit or department, and phone number (home or cell). Include the name of your warden or department head and your email address.
  2. Complete Respondent Information: Enter the name, title, unit or department for the individual you are complaining against. Specify the date(s) of the discriminatory event, listing the earliest and latest dates.
  3. Indicate Grounds for Complaint: For each type of discrimination listed (such as slurs, color discrimination, etc.), check "Yes" or "No." If you check "Yes," provide additional details where necessary.
  4. Initials and Date: Write your initials and the date in the designated area to confirm that you are the complainant.
  5. Prepare Your Statement: In the provided space, clearly write out the details of each event of discrimination, using specific descriptions of who was involved, what happened, when it took place, and where it occurred. If you need more space, attach additional pages, ensuring to number, sign, and date them.
  6. List Witnesses: Provide the names of all known witnesses and summarize what they might testify about regarding the alleged event.
  7. Report Documentation: Detail the names of all individuals you reported the alleged event to and include the corresponding dates for each report.
  8. Final Declaration: Confirm that your statement contains all essential elements and attach any additional pages as noted. Sign and date the document where indicated.

Once completed, double-check the information for accuracy. Submitting the form is a significant step toward resolving your concerns, and remaining clear and thorough will ensure that your complaint is taken seriously. Remember to keep a copy for your records!

What You Should Know About This Form

What is the purpose of the Pers 497 form?

The Pers 497 form serves as a formal complaint document for individuals wishing to report incidents of discrimination or harassment within the Texas Department of Criminal Justice. This form helps ensure that complaints are documented clearly and can be addressed appropriately.

Who should complete the Pers 497 form?

The form should be completed by any individual who believes they have experienced discrimination or harassment within their workplace. It is designed for employees of the Texas Department of Criminal Justice who seek to voice their concerns in a structured manner.

What types of discrimination can be reported on the form?

The Pers 497 form allows for the reporting of various types of discrimination, including but not limited to, race, color, gender, age, national origin, disability, and religious beliefs. Additionally, it addresses harassment and retaliation related to Equal Employment Opportunity activities.

How should I detail my complaint on the form?

It is important to provide specific information about your complaint. You should include details such as who was involved, what occurred, where it took place, and when it happened. This thoroughness will assist in the investigation process.

What information do I need to include regarding witnesses?

You should list all known witnesses who can support your allegations. Additionally, offer a summary of what you believe these witnesses can testify about regarding the incident. This information can strengthen your complaint and assist in confirming the events as you describe them.

What happens after I submit the Pers 497 form?

Once submitted, the form will be reviewed by appropriate personnel within the Texas Department of Criminal Justice. You may be contacted for further information or clarification as part of the investigation process. It is recommended to maintain a copy of your submission for your records.

Can I file my complaint with other agencies?

Yes, you have the right to file a complaint with other agencies, such as the Texas Workforce Commission’s Civil Rights Division or the U.S. Equal Employment Opportunity Commission, in addition to submitting the Pers 497 form. Understanding these options can be beneficial to you.

What rights do I have regarding my personal information on this form?

Under Texas Government Code, you have rights regarding your personal information collected by the Texas Department of Criminal Justice. You may request to be informed about what information is held about you, receive copies of it, and request corrections to any incorrect information.

Is my complaint confidential?

While efforts will be made to maintain confidentiality, it is important to understand that in some circumstances, revealing information may be necessary for a thorough investigation. Being aware of this can help set the right expectations as you proceed with your complaint.

What should I do if I feel unsafe reporting my complaint?

If you feel unsafe, it is crucial to seek guidance from a trusted individual or confide in a legal advisor. Your safety and well-being are of utmost importance, and there are resources available to support you in navigating this challenging situation.

Common mistakes

Filling out the Pers 497 form accurately is crucial for effectively addressing discrimination complaints. However, several common mistakes often occur during the completion of this form. Understanding these mistakes can help individuals provide the necessary information clearly and effectively.

One common error is leaving out specific details about the incident. The form requests comprehensive answers to the “who, what, when, and where” questions. A lack of detail can lead to confusion and ambiguity regarding the complaint. This information is vital for a thorough review of the situation.

Another frequent mistake involves checking incorrect boxes regarding the nature of the complaint. It is essential to review the definitions and ensure that the selected options accurately reflect the allegations made. Misidentifying the type of discrimination can undermine the complaint and delay proceedings.

Providing vague or unclear witness information represents another pitfall. Witness testimony can significantly strengthen a complaint. Omitting witness details, or failing to summarize their potential testimony, detracts from the credibility of the account. List all relevant individuals who may support the complaint.

Individuals sometimes fail to mention all the people to whom they reported the alleged incident. This information is critical as it shows the steps taken in addressing the issue prior to filing the complaint. Not providing these details may suggest a lack of urgency or seriousness regarding the matter.

Attention to proper formatting and paperwork is also essential. Mistakes such as not numbering, signing, or dating additional pages can lead to administrative complications. Compliance with this requirement indicates thoroughness and professionalism, which supports the credibility of the complaint.

Lastly, overlooking the signature and date fields at the end of the form can result in the complaint being considered incomplete. Both the signature and date establish accountability and provide a clear record of when the complaint was filed. These are the final steps for ensuring the submission is valid.

By avoiding these common mistakes, individuals can present their complaints more effectively, increasing the likelihood of a thorough investigation and response. Attention to detail and clear communication are fundamental to this process.

Documents used along the form

When you submit the Pers 497 form, there are several other documents and forms that may go hand in hand with your complaint. Each of these documents serves an important role in helping to clarify your situation or support your claims. Here’s a brief overview of a few commonly used forms that you might encounter.

  • EEOC Intake Questionnaire: This form allows individuals to provide details about their discrimination complaint to the Equal Employment Opportunity Commission. Completing this questionnaire can help initiate an investigation of your case at the federal level.
  • TWC Complaint Form: This document is used to file a formal complaint with the Texas Workforce Commission. It focuses specifically on workplace discrimination and ensures your concerns are recorded and addressed by state agencies.
  • Witness Statements: These are written accounts provided by individuals who may have witnessed the discriminatory events. Witness statements strengthen your case by offering additional perspectives on what occurred.
  • Incident Report: Creating a detailed report of events as they unfolded can be beneficial. This report should include dates, locations, and specific actions that you believe constitute discrimination or retaliation.
  • Supporting Documentation: This can include emails, texts, or other records that may support your claims. Providing hard evidence can enhance your credibility and substantiate your allegations.
  • TDCJ Policy Manual: Familiarizing yourself with the Texas Department of Criminal Justice’s policy manual can help you understand your rights and the procedures in place for handling discrimination complaints.

Utilizing these forms and documents can help in articulating your complaint more effectively. Each piece of information you gather plays a crucial role in helping your voice be heard. Remember, you have the right to seek support and ensure that your claims are taken seriously.

Similar forms

  • Equal Employment Opportunity (EEO) Complaint Form: Similar to the Pers 497 form, this document gathers information about workplace discrimination. It requires details on the complainant, the nature of the complaint, and any witnesses, allowing organizations to investigate claims thoroughly.

  • Discrimination Reporting Form: Like the Pers 497, this form is designed to document instances of discrimination. It includes sections for personal information, the nature of the complaint, and a narrative about the events leading up to the filing, facilitating a clear understanding of the issues.

  • Incident Report Form: This document serves to report specific incidents in the workplace. While it focuses on incidents more broadly, it requests similar details concerning the individuals involved and the chronology of events, promoting a structured approach to record-keeping.

  • Harassment Complaint Form: Just as the Pers 497 addresses different forms of harassment, this form specifically targets harassment issues in the workplace. It collects comprehensive information about the complainant, the respondent, and the incidents, essential for proper investigation.

  • Grievance Form: Often used for various workplace disputes, this document parallels the Pers 497 by capturing the complainant’s information and the specifics of the grievance, ensuring that all issues are formally recorded for review.

  • Workplace Bullying Report Form: Focused specifically on bullying in the workplace, this form aligns with the Pers 497 in its approach to detail the events, individuals involved, and witnesses, ensuring steps are taken to address any problematic behaviors.

Dos and Don'ts

When completing the Pers 497 form, there are several important dos and don'ts to keep in mind. These guidelines will help ensure that your complaint is clear and taken seriously.

  • Do: Provide Detailed Information. Include specifics about each event, such as names of people involved, dates, and locations. The clearer your account, the better.
  • Do: List All Relevant Witnesses. Mention everyone who may have witnessed the events. A summary of what they can testify about can strengthen your complaint.
  • Do: Review Your Document. Before submitting, check for errors and ensure that all required fields are complete. This helps to present a professional appearance.
  • Do: Sign and Date Your Complaint. Make sure to sign and date the form. Failure to do so can lead to processing delays.
  • Don't: Use Inflammatory Language. Avoid strong, emotional language. Instead, keep your tone professional and factual.
  • Don't: Leave Questions Unanswered. Every section of the form is important. Failing to answer questions may lead to confusion or the dismissal of your case.
  • Don't: Provide Irrelevant Information. Focus on the facts that directly relate to your complaint to maintain clarity.
  • Don't: Delay Your Submission. Timeliness matters. Submit your complaint as soon as possible after the incident to ensure the events are fresh in your memory.

By following these guidelines, you can enhance the effectiveness of your complaint and ensure it is handled appropriately.

Misconceptions

  • The PERS 497 form is only for serious crimes. Many believe that this form is reserved for severe criminal acts, but it is specifically designed for individuals to report workplace discrimination or harassment incidents.
  • Filing a PERS 497 form leads to immediate disciplinary action. Submitting this form does not guarantee immediate punishment for the accused. An investigation process will occur first to determine the validity of the claims.
  • Only employees can file a complaint using the PERS 497 form. While it is primarily for employees, individuals associated with the workplace, such as volunteers or contract workers, can also file complaints.
  • Anonymity is guaranteed when using the PERS 497 form. Unfortunately, the form does not always guarantee complete anonymity. Providing your name is necessary to facilitate the investigation process.
  • All complaints will be addressed equally. While all complaints are taken seriously, the response can vary based on the nature of the complaint and the evidence available. Each case is handled on its own merits.
  • I cannot report multiple issues on the same form. The PERS 497 form allows for multiple complaints to be listed. Complainants can report various incidents of discrimination or harassment in one submission.
  • Filing the form is the only action I need to take. It is important to remember that while filing the form is a crucial step, following up and possibly engaging with external agencies like the EEOC or TWC-CRD is advisable for comprehensive recourse.
  • There is a specific deadline for filing the form. Although there may be general timeframes for reporting certain issues, specific deadlines can vary depending on the nature of the complaint and applicable laws. It's vital to seek guidance on this.
  • Once submitted, I cannot withdraw my complaint. Complainants have the right to withdraw their complaints. However, it is encouraged to consider the potential implications of doing so before making a final decision.

Key takeaways

Filling out the Pers 497 form is an important step in addressing workplace discrimination complaints in Texas. Here are some key takeaways to keep in mind:

  • This form is used to file an EEO complaint with the Texas Department of Criminal Justice.
  • Your complaint must be detailed. Include specifics about "who, what, when, and where."
  • Make sure to list the names of witnesses who can support your claims.
  • Provide a summary of what the witness(es) may testify regarding the event.
  • Report the names of individuals you informed about the alleged event and the dates of those reports.
  • Understand that you can attach additional pages if needed. Number, sign, and date each page.
  • After submitting the form, you maintain the right to file with the Texas Workforce Commission or the U.S. Equal Employment Opportunity Commission.
  • Consider contacting the Office of the Inspector General if you wish to pursue criminal charges related to your complaint.
  • Remember, you have rights regarding the information collected about you. You can request access and correction of incorrect information.

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