Erd Case - Discrimination Complaint Wisconsin Fair Employment Law. Equal Rights Complaint Process Information Sheet Page 4
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4EQUAL RIGHTS COMPLAINT PROCESS INFORMATION SHEET
Please complete and return this sheet with your completed complaint. This information is necessary to
process your complaint effectively.
Complainant First Name
Complainant Middle Initial
Complainant Last Name
Current Date
Complainant Date of Birth (requested for identification purposes) mm/dd/yyyy
Contact Information (Important! The Complainant must notify the Equal Rights Division, if there is a change of
address or telephone number. If we are unable to locate the Complainant, the complaint
may be dismissed.)
If yes, provide the area code and telephone number
Is there a telephone number where the Complainant can be
reached between 7:45 a.m. & 4:30 p.m.?
Yes
No
Please provide the name, address, and telephone number of someone who does not reside with the Complainant but who
will know where to reach the Complainant.
Contact Person Name
Relationship to the Complainant
Street Address
City
State
Zip Code
Telephone Number
Employer Information
Approximate number of employees at all of the employer’s work locations
Type of Business
Less than 15
15-100
101-200
201-500
More
than 500
Does another company own the employer?
If yes, please provide the name of that company
Yes
No
Not Sure
Filing with other Agencies
Have you filed a complaint in this matter with any other agency?
If yes, name of agency
Date filed with the other agency
Yes
No
Settlement Information
Complete this section if the Complainant was or still is employed by the employer.
When was the Complainant hired?
What was/is the job title?
Is the Complainant still employed by the Respondent?
Yes
No
Complete this section if the Complainant is no longer employed by the employer.
How did the Complainant’s employment end?
Date Employment Ended
Pay Rate at End
Hours per Week
Discharged
Quit
Laid off
Retired
Other
If the Complainant was not promoted, what was the title of the position applied for?
Rate of Pay
Hours per Week
At this time, what is the Complainant seeking to settle the complaint?
Statistical Information
Complainant Sex:
Male
Female
Complainant Race (check appropriate box or boxes):
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Black or African American
Asian
White
Unknown
National Origin
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