If you would like to bring the questionnaire to us in person instead of mailing it to us, please click

http://www.eeoc.gov/field/index.cfm

to find out the office hours of the EEOC office closest to you.

If you would like to fax the questionnaire to us, please click

http://www.eeoc.gov/field/index.cfm

to

find out the fax number of the office nearest to you.

You should be aware that filing a charge can take up to two hours. If you find that you are having

difficulty completing the questionnaire on your own, you may call the number below for assistance.

Please be sure to:

·

Answer all questions as completely as possible.

·

Include the location where you work(ed) or applied.

·

Complete all pages and sign the last page.

·

Attach additional pages if you need more space to complete your responses.

You can find out more information about the laws we enforce and our charge-filing procedures on

our website at

www.eeoc.gov

.

If you want to file a charge about job discrimination, there are time limits to file the charge. In many

States that limit is 300 days from the date you knew about the harm or negative job action, but in

other States it is 180 days. To protect your rights, it is important that you fill out the questionnaire,

sign it, and bring it or send it to us right away.

Filling out and bringing us or sending us this questionnaire does not mean that you have filed a

charge.

This questionnaire will help us look at your situation and figure out if you are covered by the

laws we enforce. If you live within 50 miles of the office listed above, we recommend that you bring

the completed questionnaire to us to discuss your situation. If you mail the completed questionnaire

to us, someone from the EEOC should contact you by mail or by phone within 30 days. If you don't

hear from us in 30 days, please call us at

1-800-669-4000

.

Sincerely,

U.S. Equal Employment Opportunity Commission

Thank you for using the EEOC Assessment System. The information you gave us indicates that your

situation may be covered by the laws we enforce. If you want to file a charge, you can start the process

by filling out the Intake Questionnaire, signing it, and either bringing it or mailing it to the EEOC office

listed below right away. If you live within 50 miles of the EEOC office listed below, we recommend

that you bring the completed questionnaire with you to this office to discuss your situation

EQUAL EMPLOYMENT OPPORTUNITY COMMISSION

INTAKE QUESTIONNAIRE

Please

immediately

complete

the

entire

form

and

return

it

to

the

U.S.

Equal

Employment

Opportunity

Commission

("EEOC").

REMEMBER

 

 

EQUAL EMPLOYMENT OPPORTUNITY COMMISSION

INTAKE QUESTIONNAIRE

Please

immediately

complete

the

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,

generally

within

180

days

or

in

some

places

300

days

of

the

alleged

discrimination.

Upon

receipt,

this

form

will

be

reviewed

to

determine

EEOC

coverage.

Answer

all

questions

as

completely

as

possible,

and

attach

additional

pages

if

needed

to

complete

your

response(s).

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

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

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

(Check those that apply)

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.

Number of Employees in the Organization at All Locations

: Please Check (

√

) One

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:

Do You Have a Disability?

Name:

Relationship:

Address:

City:

State:

Zip Code:

Home Phone: (

)

Other Phone: (

)

Employer

Union

Employment Agency

Organization Name:

Type of Business:

Address:

City:

State:

Zip:

County:

)

Phone: (

Job Location if different from Org. Address:

Human Resources Director or Owner Name:

Phone:

Fewer Than 15

15 - 100

101 - 200

201 - 500

More than 500

Please answer each of the next three questions.

i. Are you Hispanic or Latino?

ii. What is your Race? Please choose all that apply.

American Indian or Alaska Native

Asian

White

Black or African American

Native Hawaiian or Other Pacific Islander

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

Sex: Male

Female

Yes

No

Yes

No

Other (Please Specify)

3. Your Employment Data

(Complete as many items as you can)

Job Title At Hire:

Date Hired:

Job Title at Time of Alleged Discrimination:

Name and Title of Immediate Supervisor:

Last or Current Pay Rate:

Pay Rate When Hired:

Date Quit/Discharged:

Yes

No

Are you a Federal Employee?

 

 

 

 

 

 

 

 

 

,

a

charge

of

employment

discrimination

must

be

filed

within

the

time

limits

imposed

by

law,

generally

within

180

days

or

in

some

places

300

days

of

the

alleged

discrimination.

Upon

receipt,

this

form

will

be

reviewed

to

determine

EEOC

coverage.

Answer

all

questions

as

completely

as

possible,

and

attach

additional

pages

if

needed

to

complete

your

response(s).

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

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

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

(Check those that apply)

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.

Number of Employees in the Organization at All Locations

: Please Check (

√

) One

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:

Do You Have a Disability?

Name:

Relationship:

Address:

City:

State:

Zip Code:

Home Phone: (

)

Other Phone: (

)

Employer

Union

Employment Agency

Organization Name:

Type of Business:

Address:

City:

State:

Zip:

County:

)

Phone: (

Job Location if different from Org. Address:

Human Resources Director or Owner Name:

Phone:

Fewer Than 15

15 - 100

101 - 200

201 - 500

More than 500

Please answer each of the next three questions.

i. Are you Hispanic or Latino?

ii. What is your Race? Please choose all that apply.

American Indian or Alaska Native

Asian

White

Black or African American

Native Hawaiian or Other Pacific Islander

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

Sex: Male

Female

Yes

No

Yes

No

Other (Please Specify)

3. Your Employment Data

(Complete as many items as you can)

Job Title At Hire:

Date Hired:

Job Title at Time of Alleged Discrimination:

Name and Title of Immediate Supervisor:

Last or Current Pay Rate:

Pay Rate When Hired:

Date Quit/Discharged:

 

 

2

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.

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)

Job Title Applied For

If Job Applicant,

Date You Applied for Job

Race

Sex

Age

Disability

National Origin

Color (typically a

Religion

Retaliation

Pregnancy

Other reason (basis) for discrimination (Explain).

A) Date:

Name and Title of Person(s) Responsible:

B) Date:

Action:

Name and Title of Person(s) Responsible:

difference in skin shade within the same race)

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

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

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

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?

A.

Full Name

Job Title

Description of Treatment

Race, sex, age, national origin, religion or disability

B.

Full Name

Job Title

Description of Treatment

 

 

 

 

 

 

 

 

 

3

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.

11.

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

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

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

Yes

No

Yes

No

If "YES", when did you ask?

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

How did you ask (verbally or in writing)?

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

worse

than you?

A.

Full Name

Job Title

Description of Treatment

Race, sex, age, national origin, religion or disability

B.

Full Name

Job Title

Description of Treatment

Race, sex, age, national origin, religion or disability

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

same

as you?

A.

Full Name

Job Title

Description of Treatment

Race, sex, age, national origin, religion or disability

B.

Full Name

Job Title

Description of Treatment

Race, sex, age, national origin, religion or disability

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.).

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

Describe the changes or assistance that you asked for

:

How did your employer respond to your request?

4

13. Are there any witnesses to the alleged discriminatory incidents? If yes, please identify them below and tell us what they

will say. (Please attach additional pages if needed to complete your response)

14. Have you filed a charge previously in this matter with EEOC or another agency?

16. Have you sought help about this situation from a union, an attorney, or any other source?

No

Yes

15. If you have filed a complaint with another agency, provide name of agency and date of filing:

No

Yes

Please check one of the boxes below to tell us what you would like us to do with the information you are providing on this

questionnaire.

If you would like to file a charge of job discrimination, you must do so either within 180 days from the day you knew

about the discrimination, or within 300 days from the day you knew about the discrimination if the employer is located in a place

where a state or local government agency enforces laws similar to the EEOC's laws. 

If you do not file a charge of discrimination

within the time limits, you will lose your rights.

If you would like more information before filing a charge or you have

concerns about EEOC's notifying the employer, union, or employment agency about your charge, you may wish to check Box

1. If you want to file a charge, you should check Box 2.

I want to talk to an EEOC employee before deciding whether to file a charge. I understand that by checking this box, I

have not filed a charge with the EEOC.

I also understand that I could lose my rights if I do not file a charge in time

.

Box 1

I want to file a charge of discrimination, and I authorize the EEOC to look into the discrimination I described above. I

understand that

the EEOC must give the employer, union, or employment agency that I accuse of discrimination

information about the charge, including my name.

I also understand that the EEOC can only accept charges of job

discrimination based on race, color, religion, sex, national origin, disability, age, genetic information, or retaliation for

opposing discrimination.

Box 2

A. Full Name

Job Title

What do you believe this person will tell us?

Address & Phone Number

B. Full Name

Job Title

What do you believe this person will tell us?

Address & Phone Number

Provide name of organization, name of person you spoke with and date of contact. Results, if any?

Signature

Today's Date

PRIVACY ACT STATEMENT:

This form is covered by the Privacy Act of 1974: Public Law 93-579. Authority for requesting personal data and the uses thereof are:

1.

FORM NUMBER/TITLE/DATE.

EEOC Intake Questionnaire (9/20/08).

2.

AUTHORITY.

42 U.S.C. § 2000e-5(b), 29 U.S.C. § 211, 29 U.S.C. § 626. 42 U.S.C. 12117(a), 42 USC §2000ff-6.

3.

PRINCIPAL PURPOSE.

The purpose of this questionnaire is to solicit information about claims of employment discrimination, determine whether the EEOC has

jurisdiction over those claims, and provide charge filing counseling, as appropriate. Consistent with 29 CFR 1601.12(b) and 29 CFR 1626.8(c), this questionnaire

may serve as a charge if it meets the elements of a charge.

4.

ROUTINE USES.

EEOC may disclose information from this form to other state, local and federal agencies as appropriate or necessary to carry out the

Commission's functions, or if EEOC becomes aware of a civil or criminal law violation. EEOC may also disclose information to respondents in litigation, to

congressional offices in response to inquiries from parties to the charge, to disciplinary committees investigating complaints against attorneys representing the

parties to the charge, or to federal agencies inquiring about hiring or security clearance matters

5.

WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL FOR NOT PROVIDING INFORMATION.

Providing of this information is voluntary but the failure to do so may hamper the Commission's investigation of a charge. It is not mandatory that this form be

used to provide the requested information