CONFIDENTIAL
SENDING THIS QUESTIONNAIRE IS NOT SUBMITTING A CHARGE
I was treated differently from others or denied the same opportunity in:
Refusal to Hire
Termination/Discharge
Layoff
Pay
Denial of Promotion
Demotion
Maternity
Harassment
Working Conditions
Reasonable Accommodation
Other (describe briefly)
I wish to file a charge against:
Name of Employer and/or individuals:
Address:
City: State: Zip Code:
Phone Number (include area code):
Approximate number of employees:
Are you currently employed by this Employer?
Date of hire:
Date of termination:
Present positon/Last positon held :( Please be specific)
Supervisor’s Name and Title:
Decision Maker’s Name and Title:
If you were placed by a staffing agency, please give the name and contact information for the agency:
Please briefly explain on a separate document what action(s) taken against you that you believe to be discriminatory. This
could include such things as being treated differently in hiring, termination/discharge, pay, promotions, demotions, maternity
leave, harassment, working conditions, retaliation and/or reasonable accommodations. Provide details such as names and
dates, etc. Were other persons treated differently than you? Please describe. What harm, if any, was caused as a result of that
action? Try to provide a timeline from the first date of discrimination to the latest date of discrimination including who, what,
where details.
FOR AGENCY ACTION ONLY
Action taken:
[ ] Charge taken
[ ] Not a covered basis
[ ] Information only
[ ] Actions complained of do not state
a valid claim
[ ] Not a timely charge
[ ] CP is a federal employee
[ ] No employer/employee relationship
[ ] Not enough employees
[ ] Referred to another agency:
[ ] Filed in court on same basis
[ ] Charge already filed at another agency
[ ] Other reason
(Specify):
Intake Investigator’s signature: Date:
Rev. 6/2019
