Intake Questionnaire Form - U.s. Equal Employment Opportunity Commission (Page 2 of 4) in pdf

4. What is the reason (basis) for your claim of employment discrimination?

FOR EXAMPLE, if you feel that you were treated worse than someone else because of race, you should check the box next to

Race. If you feel you were treated worse for several reasons, such as your sex, religion and national origin, you should check

all that apply. If you complained about discrimination, participated in someone else’s complaint, or filed a charge of

discrimination, and a negative action was threatened or taken, you should check the box next to Retaliation.

Race

Sex

Age

Disability

National Origin

Religion

Retaliation

Pregnancy

Color (typically a

difference in skin shade within the same race)

Genetic Information; circle which type(s) of genetic information is involved:

i. genetic testing

ii. family medical history iii. genetic services (genetic services means counseling, education or testing)

If you checked color, religion or national origin, please specify:____________________________________________________

If you checked genetic information, how did the employer obtain the genetic information?_______________________________

_________________________________________________________________________________________________________

Other reason (basis) for discrimination (Explain): ________________________________________________________________

5. What happened to you that you believe was discriminatory? Include the date(s) of harm, the action(s), and the name(s)

and title(s) of the person(s) who you believe discriminated against you. Please attach additional pages if needed.

(Example: 10/02/06 – Discharged by Mr. John Soto, Production Supervisor)

A. Date: _________________ Action: ________________________________________________________________________

_________________________________________________________________________________________________________

Name and Title of Person(s) Responsible: _____________________________________________________________________

B. Date: _________________ Action: ________________________________________________________________________

_________________________________________________________________________________________________________

Name and Title of Person(s) Responsible _____________________________________________________________________

6. Why do you believe these actions were discriminatory? Please attach additional pages if needed.

_________________________________________________________________________________________________________

7. What reason(s) were given to you for the acts you consider discriminatory? By whom? His or Her Job Title?

_________________________________________________________________________________________________________

8. Describe who was in the same or similar situation as you and how they were treated. For example, who else applied

for the same job you did, who else had the same attendance record, or who else had the same performance? Provide the

race, sex, age, national origin, religion, or disability of these individuals, if known, and if it relates to your claim of

discrimination. For example, if your complaint alleges race discrimination, provide the race of each person; if it alleges

sex discrimination, provide the sex of each person; and so on. Use additional sheets if needed.

Of the persons in the same or similar situation as you, who was treated better than you?

Full Name

Race, Sex, Age, National Origin, Religion or Disability

Job Title

Description of Treatment

A._______________________________________________________________________________________________________

_________________________________________________________________________________________________________

B._______________________________________________________________________________________________________

_________________________________________________________________________________________________________

Intake Questionnaire Form - U.s. Equal Employment Opportunity Commission Page 2

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