CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING PRE-COMPLAINT INQUIRY EMPLOYMENT The completion and submission of this Pre-Complaint Inquiry will initiate an intake interview with a Department of Fair Employment and Housing (DFEH) representative. The Pre-Complaint Inquiry is not a filed complaint. The DFEH representative will determine if a complaint can be accepted for investigation. Your submission of this document acknowledges that you have read and agree to the DFEH's Privacy Policy. COMPLAINANT: NAME: TELEPHONE NUMBER: ADDRESS: EMAIL ADDRESS: CITY/STATE/ZIP: Do you need a translator during the complaint process? Yes No If yes, indicate language RESPONDENT: NAME: TELEPHONE NUMBER: ADDRESS: CITY/STATE/ZIP: NUMBER OF EMPLOYEES: TYPE OF EMPLOYER: ADD CO-RESPONDENT: NAME/TITLE: ADDRESS: TELEPHONE NUMBER: FIRST DATE OF HARM (Month/Day/Year): LAST DATE OF HARM (Month/Day/Year): PCI-Employment Revised 12/16 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 5 1. I ALLEGE THAT I EXPERIENCED: Discrimination Harassment Retaliation BECAUSE OF MY ACTUAL OR PERCEIVED: Age - 40 and over Ancestry Association with a member of a protected class Color Disability (physical or mental) Engagement in Protected Activity Family Care or Medical Leave Genetic Information (information about genetic tests or participation in clinical research or manifestation of disease) Marital Status Medical Condition - Including cancer or cancer related medical condition or genetic characteristics (a gene, chromosome or characteristic not presently associated with symptoms of disease) Military or Veteran Status National Origin - Including language use restrictions and use and possession of a driver's license issued to persons unable to prove their presence in the U. S. is authorized under federal law Race Religion - Includes religious dress and grooming practices Sex - Gender Sex - Gender identity or Gender expression Sex - Includes pregnancy, childbirth, breastfeeding and/or related medical conditions Sexual Orientation AS A RESULT, I WAS: Asked impermissible non-job-related questions Demoted Denied a good faith interactive process Denied a work environment free of discrimination and/or retaliation Denied continuation of employer-paid health care coverage while on pregnancy disability leave Denied employment Denied equal pay Denied family care or medical leave Denied or forced to transfer Denied pregnancy leave Denied promotion Denied reasonable accommodation Denied reinstatement Denied the right to wear pants Forced to quit Laid-off Terminated Tested for genetic characteristics Other (specify) 2. Do you have an attorney who agreed to represent you in this matter? If yes, please provide the attorney's contact information. COMPLAINANT'S REPRESENTATIVE INFORMATION Attorney Name: Attorney Firm Name: Attorney Address: Attorney City, State, and Zip: Yes No PCI-Employment Revised 12/16 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 3. Briefly describe what you believe to be the reason(s) for the discrimination, harassment or retaliation. (Optional) PCI-Employment Revised 12/16 Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com DEMOGRAPHIC INFORMATION THIS INFORMATION IS OPTIONAL AND IS ONLY USED FOR STATISTICAL PURPOSES. Primary Language: Age: GENDER: Male Female Other MARITAL STATUS: Single Married Cohabitation Divorced RACE: American Indian, Native American or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other ETHNICITY: Hispanic or Latino Non-Hispanic or Latino Italian National Origin Jamaican National Origin Japanese National Origin Korean National Origin Laotian National Origin Lebanese National Origin Malaysian National Origin Mexican National Origin Nigerian National Origin Other National Origin Other African National Origin Other Asian National Origin Other Caribbean National Origin Other European National Origin Other Hispanic/Latino National Origin Other Middle Eastern National Origin Pakistani National Origin Puerto Rican National Origin Salvadoran National Origin Samoan National Origin Sri Lankan National Origin Syrian National Origin Taiwanese National Origin Thai National Origin Tongan National Origin Vietnamese National Origin NATIONAL ORIGIN: Afghani National Origin American [U.S.A.] National Origin Asian Indian National Origin Bangladeshi National Origin Cambodian National Origin Canadian National Origin Chinese National Origin Cuban National Origin Dominican National Origin Egyptian National Origin English National Origin Ethiopian National Origin Fijian National Origin Filipino National Origin German National Origin Ghanaian National Origin Guamanian National Origin Haitian National Origin Hawaiian National Origin Hmong National Origin Indonesian National Origin Iranian National Origin Iraqi National Origin Irish National Origin Israeli National Origin PCI-Employment Revised 12/16 Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com DEMOGRAPHIC INFORMATION THIS INFORMATION IS OPTIONAL AND IS ONLY USED FOR STATISTICAL PURPOSES. DISABILITY: AIDS or HIV Blood / Circulation Brain / Nerves / Muscles Digestive / Urinary / Reproduction Hearing Heart Limbs [ Arms / Legs ] Mental Sight Speech / Respiration Spinal / Back / Respiration Other Disability RELIGION: Agnostic Atheist Bahai Buddhism Catholicism Christianity Confucianism Hinduism Islam Jehovah's Witness Judaism Neo-Paganism Nonreligious Protestantism Primal-indigenous Quakers Rastafarianism Spiritism Shinto Sikhism Taoism Unitarian-Universalism Zoroastrianism Other PCI-Employment Revised 12/16 Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com California Department of Fair Employment & Housing Privacy Policy The California Department of Fair Employment & Housing (DFEH) has adopted this Privacy Policy, effective January 1, 2017. DFEH values the security and privacy of your personal information and is committed to protecting your privacy rights. The DFEH seeks only to collect relevant personal information that enables us to assist you in investigating and resolving complaints of discrimination as prescribed by California Government Code sections 11135 et seq., 12900 et seq., and California Civil Code sections 51, 51.7, 52.5, and 54 et seq. All personal information we collect is governed by the State of California Information Practices Act of 1977 (Civ. Code, §§ 1798-1798.78), Government Code sections 11015.5and 11019.9, and the California Public Records Act (Go