CIS-U. 12/2016 COMPLAINANT INFORMATION SHEET (For All Cases not related to Housing Discrimination) State of IllinoisDepartment of Human Rights Office Use Only: Control No: Inv. Init. Date: Instructions: Read this entire form and all of the instructions carefully before completing. All applicable questions should be answered. This form must be postmarked or received by IDHR within 180 days of the date of the alleged discrimination. IDHR must establish if it has the right under the law to investigate your claim. If IDHR accepts your claim of discrimination, information will be typed on an official charge form. The charge form must be signed, notarized and returned to IDHR in a timely manner. This form must be signed and dated. Use additional sheets if necessary. THIS IS NOT A CHARGE. If IDHR accepts your claim, we will send you a charge form for signature. 1.COMPLAINANT INFORMATION Name: Address: Apt No: City: State: ZIP: Phone No: E-Mail: Alt. Phone No: Alt. Phone No: Please provide the following information for statistical purposes only. Country of National Origin: Date of Birth: Sex: 2.WHO CAN WE CALL IF WE CANNOT CONTACT YOU Make sure their mailing addresses are different from your mailing address. Your charge couldbe dismissed if you do not provide this information and we are unable to locate you. Name: Address: Apt No: City: State: ZIP: Phone No: Name: Address: Apt No: City: State: ZIP: Phone No: 3.RESPONDENT INFORMATION Write out the full legal name of the company or organization that you believe discriminated against you in Illinois (i.e. theRespondent). (Employer, Employment Agency, Financial Institution, Union, Place of Public Accommodation, School or University, etc.) Name: Address: City: State: ZIP: Phone No: County: Website: 4.WHAT IS YOUR RELATIONSHIP WITH THE RESPONDENT EMPLOYMENT: Respondent is my Employer / Former Employer / Potential Employer. FINANCIAL CREDIT: Respondent is a Financial Institution, such as a bank or an insurance company, to which I applied for an account or line of credit. PUBLIC ACCOMMODATIONS: Respondent is a Public Entity or Place of Business (of which I am not a current, former, or potential employee), such as a Store, Restaurant, Public Park, Educational Program, or Public Official, and has denied me a service or access or has subjected me to a form of pervasive harassment. SEXUAL HARASSMENT IN EDUCATION: Respondent is or represents an Educational Institution in which I (or my minor child) am currently, recently, or I have applied to be enrolled that I believe has sexually harassed me (or my minor child), or has retaliated against me (or my minor child) for reporting, opposing or for participating in an investigation of sexual harassment. Yes No Yes NoNOTE: IDHR Can only investigate if the employer has 15 or more employees in Illinois. If the Respondent is an employer, does the Respondent employ: If your alleged claim of discrimination is related to Housing, such as buying or renting a house or apartment or refused a request to modify your housing, please STOP and fill out an IDHR Housing Complainant Information Sheet. What type of business or organization is the Respondent? For example, a Private Employer, Public or Non-Profit Organization, State or Local Government, School or University (specify Public or Private, and if it is Elementary, Secondary, Vocational, etc., and your current enrollment status), Employment Agency, Municipality, Union, Bank, Insurance Company, Individual, etc. Office Use Only100 W. Randolph St., 10th Floor, Attn. Intake Unit, Chicago, IL 60601; 312-814-6200; 866-740-3953 (TTY); INTERVIEWS MON.-THURS. 8:30 AM to 4:00 PM In Springfield: 222 South College, Room 101-A, Attn. Intake Unit, Springfield, IL62704; 217-785-5100; 866-740-3953 (TTY) WEBSITE: www.illinois.gov/dhr/ CHICAGO FAX: 312-814-6251 SPRINGFIELD FAX: 217-785-510615 or more employees in the state of Illinois15 or more employees in the United States CIS-U. 12/2016COMPLAINANT INFORMATION SHEETIllinois Department of Human Rights 5.DESCRIPTION OF THE ISSUES AND BASES YOU ARE REQUESTING IDHR TO INVESTIGATE Each of your COMPLAINTS of discrimination must be composed of two parts: the ISSUE and the BASIS. The ISSUE is the harm or action that was taken against you. (Such as being discharged from your place of employment or being denied access to a public service.) The BASIS is the legally protected class you believe is the reason for the action that was taken against you. IDHR can only investigate charges alleging specific BASES of discrimination:Age (+40)AncestryNational OriginSexual OrientationPhysical Disability or Mental Disability (unrelated to ability to do the job)RacePregnancyMilitary StatusSexual HarassmentArrest Record (or criminal history record ordered expunged, sealed or impounded), ColorReligionCitizenship StatusOrder of Protection StatusAiding and Abetting / Coercion (helping or forcing a person to commit discrimination)SexMarital StatusGender IdentityUnfavorable Military DischargeRetaliation (complained about unlawful discrimination, filed a prior discrimination claim, or testified at a discrimination hearing)Your Charge of Discrimination can have multiple COMPLAINTS. Your BASIS can be the cause of more than one ISSUE, and each ISSUE could have been caused by more than one BASIS. If your complaint is of SEXUAL HARASSMENT, RETALIATION, AIDING AND ABETTING, or COERCION, your Issue and Basis are the same. IDHR cannot investigate: * Unfair Employment, Public Accommodation, or Union Practices such as political affiliations, personality conflicts, etc., unless such actions are alleged to be for one or more of the Bases listed above * Charges against the federal government or federal officials. * Employment charges against companies with fewer than fifteen (15) employees, unless the charge alleges sexual harassment, pregnancy, retaliation, or physical or mental disability discrimination, or unless the employer is a public contractor. * Curriculum content or course offerings of Educational Programs or Institutions. * Prison Facilities. * Educational institutions regarding discrimination in educational programs other than sexual harassment. 1st COMPLAINT: Describe the ISSUE or harm. Be specific and concise. (Common Issues include: Discharge from place of employment, Retaliation for filing a complaint of discrimination, Unwelcome sexual advances, Denied access to a public facility, Denied a loan, Creating an intimidating or hostile environment, or Failure to make a reasonable accommodation.) BASIS: (As described above) Date(s) of Action: Name and Job Title of the person who commited the action or gave you this information: Why do you feel discriminated against because of the basis you have identified, or how has this action created a hostile or offensive environment? How were others in your situation treated? 2nd COMPLAINT: Describe the ISSUE or harm. Be specific and concise. (Common Issues include: Discharge from place of employment, Retaliation for filing a complaint of discrimination, Unwelcome sexual advances, Denied access to a public facility, Denied a loan, Creating an intimidating or hostile environment, or Failure to make a reasonable accommodation.) BASIS: (As described above) Date(s) of Action: Name and Job Title of the person who commited the action or gave you this information: Why do you feel discriminated against because of the basis you have identified, or how has this action created a hostile or offensive environment? How were others in your situation treated?Please use additional sheets as necessary to provide the above information for each complaint. CIS-U. 12/2016Illinois Department of Human Rights COMPLAINANT INFORMATION SHEET 6.IF YOU HAVE BEEN EMPLOYED BY THE RESPONDENT, PLEASE FILL IN THE FOLLOWING: Job Title: Were you on probation? Yes No Date Hired: Salary: Hourly Weekly Bimonthly Monthly Annually Department: Supervisor: 7.SPECIAL BASES 7A. If your claim involves SEXUAL HARASSMENT: Name of the harasser: Job Title of harasser: Do you want the sexual harasser charged separately as an additional respondent? Yes No If "Yes", provide contact information for the harasser. Address: City: State: ZIP