STATE OF CALIFORNIA STATE AND CONSUMER SERVICES AGENCY DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING Interview Date: FOR OFFICIAL USE ONLY Processing Time: :MIN Approval: Action Taken: Interviewer: :HR Computer Entry: PRE-COMPLAINT QUESTIONNAIRE - EMPLOYMENT The information requested on this form will assist the Department in helping you. There is no guarantee that the information submitted will result in an investigation. Please check or answer only those questions that apply. PLEASE PRINT NAME DATE ______________ First ADDRESS ___________ Middle Last ____________ Street Apt. Number TELEPHONE NUMBER: WORK ( City County ) HOME ( Area Code ZIP Code ) Area Code I prefer to be contacted by telephone at work/home: Days: Time: Person to contact if you cannot be reached or if you move: Name TELEPHONE ( ) Area Code ___________ I WISH TO COMPLAIN AGAINST: (Name and address of company, government entity [city, county, state], employment agency, union, etc.) NAME ______________ ADDRESS _______________ Street TELEPHONE NUMBER: City WORK ( ) Area Code I WISH TO COMPLAIN AGAINST: NAME ______________ ZIP Code (Other named individuals who were involved in this particular complaint.) TITLE ADDRESS County NUMBER OF EMPLOYEES (Estimate, if necessary) Job Site ______ Company-Wide ______ _________ TELEPHONE ( ) __ Area Code ____________ (if known) Street City County ZIP Code City County ZIP Code EMPLOYER LISTED ON W-2 FORM: NAME ______________ ADDRESS _____________ (if known) Street (CONTINUE ON BACK IF NECESSARY) 1. I believe I was discriminated against because of my (please circle): Race Sex Cancer Pregnancy Color Sexual Orientation Genetic Characterisitcs Marital Status Religion ___________________ ____________________________ (Please specify) Disability (including AIDS) ________________ (Please specify) Age (40 and over) Denial of Family Care Leave National Origin/Ancestry (Please specify) 2. Circle the discriminatory treatment and indicate the date occurred: Terminated/Laid Off _____________ Denied Promotion _________________ Harassed ____________________ Denied Leave (Pregnancy/Family Care Leave) ________________ Denied Accommodation _____________ Denied Equal Pay _____________ Denied Accommodation for Pregnancy ______________________ Impermissible Non-Job-Related Inquiry _________________________________ Retaliation ____________________ Not Hired _____________ Other ____________________________________________________________________________________ DFEH-600-03I (06/03) American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com 3. Why do you believe the unfair treatment was discrimination? (If others were treated better than you, give names, addresses and examples.) 4. List the names, addresses, job titles and telephone numbers (if possible) of witnesses, co-workers, or others you feel could provide evidence. Explain what you think each witness will be able to tell us. Name and Address Title/Relationship Telephone Numbers Home Work Can provide information regarding: Name and Address Home Title/Relationship Telephone Numbers Work Can provide information regarding: (Use extra sheets of paper for additional witnesses, if necessary.) 5. EMPLOYMENT DATA: (Complete as many items as you can.) A. B. C. D. E. Date hired or applied for job: Job title/salary at time of discrimination: Name and title of immediate supervisor or interviewer: If you? your employment was terminated, who replaced: If your employment was terminated or if you were refused a job, have you since been employed? Date of hire: Salary: Job Title: F. If not hired: < How did you know about the job and/or salary? < Did you apply by written application or verbally? < To whom did you submit the application? < How did you find out you had been refused? < Who got the job, salary, etc. (if known)? Yes No Date Date 6. Have you filed a complaint with the U.S. Equal Employment Opportunity Commission (EEOC) before coming to DFEH? Yes ______ No ______ Date _______________________ 7. Have you talked to an attorney concerning this problem? Yes ______ No ______ NAME TELEPHONE ( ) Area Code ADDRESS 8. PERSONAL DATA: PRIMARY LANGUAGE RACE/ETHNICITY (Check box that best describes) Native American African-American African – Other Caucasian (non-Hispanic) ____________________________ SOCIAL SECURITY NUMBER: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ (The Federal Privacy Act of 1974 prohibits a state government agency from requiring disclosure of an individual's Social Security Number. Disclosure of your Social Security Number is voluntary.) Asian/Pacific Islander (specify) ________________ __________________ Hispanic (specify) DATE OF BIRTH ___ ___ / ___ ___ / ___ ___ SEX: Male Female DFEH-600-03I (06/03) American LegalNet, Inc. www.FormsWorkflow.com DO NOT WRITE IN THIS AREA INTERVIEWER'S NOTES Complainant's assertions: What does Complainant say the employer's position will be? Comparative data/relevant information: What does Complainant want as a remedy? Complaint taken for investigation: Yes ___ No ___ If taken for filing purposes only, explain why: If NO, was "b" offered? Yes ___ No ___ If not taken, rationale: Complainant advised of Pilot Mediation Program? Yes ___ No ___ Complainant advised of statute of limitations? Yes ___ No ___ Complainant advised of other agencies? Yes ___ No ___ DFEH CODE: LAW ____ FOR OFFICIAL USE ONLY BASIS ___ ___ ACT ___ ___ REJECT ___ Date statute runs: PUBLIC ___ DFEH-600-03I (06/03) American LegalNet, Inc. www.FormsWorkflow.com