City of Worcester

webmaster@worcesterma.gov

455 Main Street, Worcester, MA, 01608, US

City of Worcester Letterhead with City Seal and City Manager Eric Batista's Name

Investigations Division Intake Form

Full Name

First Name

Initial

Last Name

Phone Number

Email

Are you a City employee?

Yes

No

In which department do you work?

Mailing Address: (If you do not have a mailing address, please contact the Investigations Division directly at 508-799-1995 or visit us at 51 Sever Street)

Street Address

City

State

Zip

Briefly in 1-3 sentences explain what happened that led you to reach out to us. Provide any identifying information for the individual you are reporting, including name, title, and department, as you are able.

Which of the following do you believe motivated this treatment (check all that apply)?

Race

Color

Ancestry

National Origin

Sex

Sexual Orientation

Gender Identity

Religion

Age (Over 40)

Military Status

Disability

Pregnancy

Genetics

Retaliation

When meeting with Investigations Division staff, you will be asked to explain the reason for your belief that anything you checked was a motivating factor.

Please explain what act you engaged in that motivated the retaliation:

Please identify the best dates and times over the next two weeks to discuss this matter further with Investigations Division staff:

disregard this