Intake Questionnaire Form - U.s. Equal Employment Opportunity Commission printable pdf download

U.S. EQUAL EMPLOYMENT OPPORTUNITY COMMISSION

INTAKE QUESTIONNAIRE

Please immediately complete this entire form and return it to the U.S. Equal Employment Opportunity

Commission (“EEOC”). REMEMBER, a charge of employment discrimination must be filed within the

time limits imposed by law, within 180 days or in some places within 300 days of the alleged discrimination. When we receive

this form, we will review it to determine EEOC coverage. Answer all questions completely, and attach additional pages if

needed to complete your responses. If you do not know the answer to a question, answer by stating “not known.” If a

question is not applicable, write “N/A.” (PLEASE PRINT)

1. Personal Information

Last Name: _______________________________ First Name: _______________________________ MI: _________________

Street or Mailing Address: _______________________________________________ Apt or Unit #: ______________________

City: _____________________________ County: ____________________ State: _________ Zip: _______________________

Phone Numbers: Home: (_____) _________________________ Work: (_____) ______________________________________

Cell: (_____) _________________________ Email Address: ______________________________________________________

Date of Birth: ______________

Sex:

Male

Female

Do You Have a Disability?

Yes

Please answer each of the next three questions.

i. Are you Hispanic or Latino?

Yes

ii. What is your Race?

Please choose all that apply.

American Indian or Alaskan Native

Asian

White

Black or African American

Native Hawaiian or Other Pacific Islander

iii. What is your National Origin (country of origin or ancestry)? ___________________________________________________

Please Provide The Name Of A Person We Can Contact If We Are Unable To Reach You:

Name:

Relationship: ___________________________________

Address: __________________________________ City: ____________________ State: ______ Zip Code: ________________

Home Phone: (____) _________________________ Other Phone: (____) _________________________

2. I believe that I was discriminated against by the following organization(s): (Check those that apply)

Employer

Union

Employment Agency

Other (Please Specify) ___________________________________

Organization Contact Information (If the organization is an employer, provide the address where you actually worked. If you

work from home, check here

and provide the address of the office to which you reported.) If more than one employer is

involved, attach additional sheets.

Organization Name: _______________________________________________________________________________________

Address: ________________________________________ County: _________________________________________________

City: ____________________________ State: ____ Zip: ____________ Phone: (____) _________________________________

Type of Business: __________________ Job Location if different from Org. Address: __________________________________

Human Resources Director or Owner Name: ____________________________________ Phone: (____) ___________________

Number of Employees in the Organization at All Locations: Please Check (√) One

Fewer Than 15

15 – 100

101 – 200

201 – 500

More than 500

3. Your Employment Data (Complete as many items as you are able.) Are you a federal employee?

Yes

Date Hired: ________________________ Job Title At Hire: ______________________________________________________

Pay Rate When Hired: _________________________ Last or Current Pay Rate: ______________________________________

Job Title at Time of Alleged Discrimination: _______________________ Date Quit/Discharged:_________________________

Name and Title of Immediate Supervisor: _____________________________________________________________________

If Job Applicant, Date You Applied for Job ______________ Job Title Applied For __________________________________

Intake Questionnaire Form - U.s. Equal Employment Opportunity Commission

Related Articles

Related forms

Related Categories