Fillable EQUAL EMPLOYMENT OPPORTUNITY QUESTIONNAIRE/AFFIDAVIT (State of North Dakota)

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EQUAL EMPLOYMENT OPPORTUNITY QUESTIONNAIRE/AFFIDAVIT (State of North Dakota)

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The EQUAL EMPLOYMENT OPPORTUNITY QUESTIONNAIRE/AFFIDAVIT (State of North Dakota) form is 3 pages long and contains:

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  • 48 check-boxes
  • 111 other fields

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File type: PDF

U.S.A. forms for State of North Dakota

BROWSE STATE OF NORTH DAKOTA (ND) FORMS

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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
SFN 14543 (11-2021)
Page 2 of 3
Work History with Above Company (Use "N/A" if information is not available or unknown at this time)
Date(s) Applied Position(s) Applied For
Date(s) Interviewed Name and Title of Individuals Who Interviewed You
Date of Employment
Name and Title of Individuals Who Hired You
Position When Hired Rate of Pay Estimated Monthly Salary
Per Period of Work
Hour Day Month Year
Current Position (If Still Employed) Rate of Pay Estimated Monthly Salary
Per Period of Work
Hour Day Month Year
Last Position Held (If Not Employed) Rate of Pay Estimated Monthly Salary
Per Period of Work
Hour Day Month Year
Explain the reason(s) given by the company for their employment action(s) taken against you. Include names and dates when appropriate.
List Any Employees Who Were Treated Differently Than You - Attach additional sheets if necessary
Name Title Name Title
Question No Yes NA Date
Explain "Yes" Answers - Attach additional sheets if
necessary
Did you ever complain to your boss or the company about
discriminatory acts against you by anyone on the job?
Are you covered by a union or collective bargaining
agreement?
Did you complain to a union about discriminatory acts?
If the company has a grievance procedure/policy, did you
file a grievance? If so, when?
Have you filed a charge of discrimination with another
agency? If so, with whom?
PLEASE ATTACH A STATEMENT that describes what happened including: background history, a brief description of your work,
how and/or why you feel discriminated against, by whom, when, where. Be sure to include supporting evidence such as
witnesses, witness statements, and documents when possible. Please keep your statements relative to the basis of the charge.
Be sure to include all dates (day, month, year) and names as accurately as possible. If filing a complaint based on disability,
please provide appropriate medical documentation.
SFN 14543 (11-2021)
Page 3 of 3
Describe Remedies You Are Seeking for Relief in this Charge (What it would take to resolve the issue(s) you are alleging)
By typing my name here, I certify that the information I have provided above is true and complete to the best of my knowledge and belief,
and I adopt this as my online signature. This complaint form and accompanying statements must be signed in order to process a charge of
discrimination.
I declare under the penalty of perjury that the foregoing is true and correct.
Signature
Date Signed
NOTICE: Anything you submit to us in paper will be scanned to an electronic version and the original destroyed.
RETURN TO: labor@nd.gov
North Dakota Department of Labor and Human Rights
600 E Boulevard Ave Dept 406
Bismarck ND 58505-0340
701-328-2660 Fax: 701-328-2031
ND Toll-Free: 1-800-582-8032
TTY: 1-800-366-6888
www.nd.gov/labor
List Witnesses Who Can Support Your Allegations - Attach additional sheets if necessary
Name Work Relationship Address Telephone Number
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EQUAL EMPLOYMENT OPPORTUNITY QUESTIONNAIREAFFIDAVIT (State of North Dakota)

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Completed 22 April 2022

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