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EQUAL EMPLOYMENT OPPORTUNITY QUESTIONNAIRE/AFFIDAVIT
NORTH DAKOTA DEPARTMENT OF LABOR AND HUMAN RIGHTS
SFN 14543 (11-2021)
Name (First, Last) Home Telephone Number Cell Phone Number
Address
StateCity ZIP Code
Email Address
Name of Alternate Contact
Alternate Contact Telephone Number
Are you a Veteran?
Yes No
Reason You Were Discriminated Against: (Check ALL that apply)
Age - Date of Birth:
Color - Specify:
Disability
Lawful Activity: Off the employer's premises during non-
working hours and not in direct conflict with essential
business-related interests of employer
Marital Status - Check one:
Married Divorced Single
National Origin - Specify:
Race - Specify:
Religion - Specify:
Retaliation: You have filed a charge in the past, testified, or
opposed discrimination at work
Sex:
Male Female Gender Identity
Sex Stereotyping Sexual Orientation
Sex/Pregnancy
Status with regard to Public Assistance
Acts of Discrimination Were Related To: (Check ALL that apply)
Demotion
Discharge
Failure to Hire
Failure to Promote
Failure to Recall
Constructive Discharge (Forced to Resign)
Hostile Environment
Harassment
Pay/Compensation
Racial Harassment
Reasonable Accommodation
Reduction in Force
Released Confidential Medical
Information
Religious Accommodations
Sexual Harassment
Other Terms, Conditions, or Privileges
of Employment - Explain Below:
Explain Other Conditions
Name of Company/Organization You Believe Discriminated and/or Retaliated Against You Telephone Number
Address
City
State
ZIP Code
Name of Contact (Owner, CEO, HR Director, Manager, etc.) Title Telephone Number
Name of Immediate Supervisor Title
Name of Other Supervisor Title
Approximate Number of Employees
Last Date of Discrimination
Consent to Receiving Correspondence Exclusively at this Email Address
Yes No