Intake Questionnaire Form - U.s. Equal Employment Opportunity Commission (Page 3 of 4) in pdf

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

Full Name

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

Job Title

Description of Treatment

A._______________________________________________________________________________________________________

_________________________________________________________________________________________________________

B._______________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

Full Name

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

Job Title

Description of Treatment

A._______________________________________________________________________________________________________

_________________________________________________________________________________________________________

B._______________________________________________________________________________________________________

_________________________________________________________________________________________________________

Answer questions 9-12 only if you are claiming discrimination based on disability. If not, skip to question 13. Please tell

us if you have more than one disability. Please add additional pages if needed.

9. Please check all that apply:

Yes, I have a disability

I do not have a disability now but I did have one

No disability but the organization treats me as if I am disabled

10. What is the disability that you believe is the reason for the adverse action taken against you? Does this disability

prevent or limit you from doing anything? (e.g., lifting, sleeping, breathing, walking, caring for yourself, working, etc.).

_________________________________________________________________________________________________________

11. Do you use medications, medical equipment or anything else to lessen or eliminate the symptoms of your disability?

Yes

If “Yes,” what medication, medical equipment or other assistance do you use?

_________________________________________________________________________________________________________

12. Did you ask your employer for any changes or assistance to do your job because of your disability?

Yes

If “Yes,” when did you ask? ________________ How did you ask (verbally or in writing)? _____________________________

Who did you ask? (Provide full name and job title of person)

_________________________________________________________________________________________________________

Describe the changes or assistance that you asked for: ____________________________________________________________

_________________________________________________________________________________________________________

How did your employer respond to your request? ________________________________________________________________

_________________________________________________________________________________________________________

Intake Questionnaire Form - U.s. Equal Employment Opportunity Commission Page 3