U.S. EQUAL EMPLOYMENT OPPORTUNITY COMMISSION Thank you for contacting us. 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 questionnaire right away and mailing it back to us. Please send it to the EEOC office address given to you by the EEOC staff person you spoke to or the address provided to you online. If you would like to bring the questionnaire to us in person instead of mailing it to us, please call the number listed below to make sure the office will be open. You should be aware that filing a charge can take up to two hours. Please be sure to: • Answer all questions as completely as possible. • Include the location where you work(ed) or applied. • Complete all pages. • Attach additional pages if you need more space to complete your responses. • Contact a field office if you have questions about this form or if you would like to visit the office to finish filing a charge. You can find out more information about the laws we enforce and our charge-filing procedures on our web site 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 and send it to us right away. Filling out and 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 we can help you. After you send us this questionnaire, someone from the EEOC should be contacting you by mail or by phone within 30 days to talk to you. If you don’t hear from us in 30 days, please call us back at 1-866-408-8075. Sincerely, U.S. Equal Employment Opportunity Commission Phone: 1-800-669-4000 TTY: 1-800-669-6820 Internet: www.eeoc.gov Email: info@eeoc.gov American LegalNet, Inc. www.FormsWorkflow.com 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 Last Name: First Name: MI: Street or Mailing Address: Apt Or Unit #: City: County: Phone Numbers: Home: ( Cell: ( State: ) Work: ( ) ZIP: ) Email Address: Date of Birth: Sex: Male Female: Do You Have a Disability? Yes Please answer each of the next three questions. i. Are you Hispanic or Latino? ii. What is your Race? Please choose all that apply. Black or African American Yes No No American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Asian White iii. What is your National Origin? Provide The Name Of A Person We Can Contact If We Are Unable To Reach You: Name: Relationship: Address: Home Phone: ( City: ) Other Phone: ( State: Zip Code: ) I believe that I was discriminated against by the following organization(s): (Check those that apply) Employer 2. Union Employment Agency Other (Please Specify) Organization Contact Information Organization #1 Name: Address: County: City: State: Zip: Phone: ( ) Job Location if different from Org. Address: Type of Business: Human Resources Director or Owner Name: Phone: Number of Employees in the Organization at All Locations: Please Check (√) One Less Than 15 15 - 100 101 - 200 201 - 500 More 500 Organization #2 Name: Address: City: County: State: Zip: Phone: ( ) American LegalNet, Inc. www.FormsWorkflow.com 2 Job Location if different from Org. Address: Type of Business: Human Resources Director or Owner Name: Phone: Number of Employees in the Organization at All Locations: Please Check (√) One Less Than 15 15 - 100 101 - 200 201 - 500 More 500 3. Your Employment Data (Complete as many items as you can) Date Hired: Job Title At Hire: Pay Rate When Hired: Last or Current Pay Rate: Job Title at Time of Alleged Discrimination: Name and Title of Immediate Supervisor: If Applicant, Date You Applied for Job Job Title Applied For 4. What is the reason (basis) for your claim of employment discrimination? FOR EXAMPLE, if you are over the age of 40 and feel you were treated worse than younger employees or you have other evidence of discrimination, you should check (√) AGE. If you feel that you were treated worse than those not of your race or you have other evidence of discrimination, you should check (√) RACE. If you feel the adverse treatment was due to multiple reasons, such as your sex, religion and national origin, you should check all three. If you complained about discrimination, participated in someone else's complaint or if you filed a charge of discrimination and a negative action was threatened or taken, you should check (√) RETALIATION. Race Sex Age Disability National Origin Color Religion Retaliation Pregnancy Other reason (basis) for discrimination (Explain). 5. What happened to you that you believe was discriminatory? Include the date(s) of harm, action(s) and include the name(s) and title(s) of the persons who you believe discriminated against you. (Example: 10/02/06 Written Warning from Supervisor, Mr. John Soto) A) Date: Action: Name and Title of Person(s) Responsible: B) Date: Action: Name and Title of Person(s) Responsible: Describe any other actions you believe were discriminatory. (Attach additional pages if needed to complete your response.) American LegalNet, Inc. www.FormsWorkflow.com 3 6. What reason(s) were given to you for the acts you consider discriminatory? By whom? Title? 7. Name and describe others who were in the same situation as you. Explain any similar or different treatment. Who was treated worse, who was treated better, and who was treated the same? Provide race, sex, age, national origin, religion, and/or disability status of comparator if known and if connected with your claim of discrimination. Add additional sheets if needed. Full Name 1. Job Title Description 2. 3. Answer questions 8-10 only if you are claiming discrimination based on disability. If not, skip to question 11. 8. Please check all that apply: Yes, I have an actual disability I have had an actual disability in the past No disability but the organization treats me as if I am disabled 9. If you are alleging discrimination because of your disability, what is the name of your disability? How does your disability affect your daily life or work activities, e.g., what does your disability prevent or limit you from doing, if anything? (Example: lifting, sleeping normally, breathing normally, pulling, walking, climbing, caring for yourself, working, etc.). 10. Did you ask your employer for any assistance or change in working condition because of your disability? Yes No Did you need this assistance or change in working condition in order to do your job? Yes No If "YES", when? person To whom did you make the request? Provide full name of How did you ask (verbally or in writing)? Describe the assistance or change in working condition requested? American LegalNet, Inc. www.FormsWorkflow.com 4 11. Are there any witnesses to the alleged discriminatory incidents? If yes, please identify them below and indicate what they will say. Add additional pages if necessary. NAME JOB TITLE ADDRESS & PHONE NUMBER NAME JOB TITLE ADDRESS & PHONE NUMBER NAME JOB TITLE ADDRESS & PHONE NUMBER A. B. C. 12. Have you filed a charge previously in this matter with EEOC or another agency? Yes No 13. If you have filed a complaint with another agency, provide name of agency and date of filing: 14. Have you sought help about this situation from a union, an attorney, or any other source? Yes No - If yes, from whom and when? Provide name of organization, name of person you spoke with and date of contact. Results, if any? 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 within either 180 or 300 days from the day you knew about the discrimination. The amount of time you have depends on whether the employer is located in a place where a state or local government agency has 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 want to file a charge, you should check Box 1, below. If you would like more information before deciding whether to file a charge or you are worried or have concerns about EEOC's notifying the employer, union, or employment agency about your filing a charge, you may wish to check Box 2, below. 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, or retaliation for opposing discrimination. Box 2 I want to talk to an EEOC employee before deciding whether to file a charge of discrimination. 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. American LegalNet, Inc. www.FormsWorkflow.com 5 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) 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. The providing of this information is voluntary but the failure to do so may hamper the Commission's investigation of a charge of discrimination. It is not mandatory that this form be used to provide the requested information. American LegalNet, Inc. www.FormsWorkflow.com