Erd Case - Discrimination Complaint Wisconsin Fair Employment Law. Equal Rights Complaint Process Information Sheet
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4ERD Case #
Discrimination Complaint
For office use only
State of Wisconsin
CR
Wisconsin Fair Employment
Dept. of Workforce Development
Equal Rights Division
Law
Sections 111.31-111.395, WI
Authorization for this form is provided under Section 111.39(1), Wisconsin Statutes.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m),
Stats
Wisconsin Statutes].
READ instructions on page two FIRST then type or print in black ink.
1. Complainant Information
2. Respondent Information
First Name
The company, agency, or union you believe
discriminated against you. Name only ONE
Respondent per form. Do not name an individual
Middle Initial
person as Respondent.
Name
Last Name
Street Address/PO Box
City
State
Zip Code
Street Address/PO Box
Telephone Number
City
State
Zip Code
E-Mail Address
Telephone Number
Ext.
May we call the Complainant at work?
In what Wisconsin county did the violation take place?
Yes
No
Work Telephone Number
Ext.
3. CHECK ONLY THE BOXES THAT WERE THE REASON FOR DISCRIMINATION
If you checked a box with an *, the statement in that box must be completed.
I believe the Respondent(s) discriminated or took action against me because
of my race *
of my conviction record
of polygraph testing
which is
of my creed (religion) *
of my age (40 or older) *
of my military service
which is
my date of birth is
of my sex *
of my marital status *
of my use or nonuse of
which is
which is
lawful products
of my pregnancy or maternity
of my sexual orientation *
of genetic testing
which is
of my national origin/ancestry *
of my color *
of my arrest record
which is
which is
of my disability *
I filed a previous discrimination
I opposed discrimination in
which is
complaint with Equal Rights
the workplace (refer to
Enter Case Number: CR
directions (c))
I declined to attend a meeting or to participate in a Communication about Religious matters or political matters
I previously filed a family/medical leave
I testified or assisted with a discrimination
complaint with the Equal Rights Division
complaint filed with the Equal Rights Division
Enter Case Number: CR
Enter Case Number: CR
I previously filed a wage and hour complaint with
The employer believed that I was going to file a
the Equal Rights Division
wage and hour complaint with the Equal Rights
Enter Case Number: LS
Division
4. Dates of discrimination (Required; estimate if unsure)
Date the discrimination began? Mm/dd/yyyy
Date of the most recent discrimination? Mm/dd/yyyy
ERD-4206-E (R. 11/2010)
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