Employment Discrimination Complaint/Intake Questionnaire  
 
 Bullet Complainant Information: (All fields are required and must have a response)
  First Name:    Middle Initial:    Last Name:

Address:    City:    State:    Zip:

Home Phone:    Other Phone:    E-mail:

Date of Birth:    Gender: Male  Female  No Response
 
 Bullet Basis on which you believe you have been discriminated against: (Select all applicable)
  Age    Color    Disability    Equal Pay/Compensation    Genetic Information    National Origin    Pregnancy

Race    Religion    Retaliation    Sex    Sexual Harassment    Sexual Orientation    Other
 
 Bullet National Origin/or Ethnic Group: (Please select one)
  African American    American Indian    Arab, Afghani, Middle Eastern    Asian American    East Indian    Hispanic    White

Other    No Response
 
 Bullet State Agency Against Which Complaint is Being Filed:
  Agency/Employer:     Division/Dept:    # of Employees:

Supervisor Name:     Supervisor Phone:

Address:    City:    State:    Zip:
 
 Bullet Complaint/Discriminatory Incident(s) Description:
  In date order (chronologically), describe the harm or employer action for which you are filling a complaint. Be sure to include dates, times, names of witnesses, and what specifically was said and/or happened.

    
 
 Bullet I swear to the best of my knowledge and belief that the information contained herein is complete and accurate.
  Name:    Date:



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