C omplaint of Discr imination In E mployment U.S. Department of Labor Under Federal Governm ent Contracts Employment S tandards Administration Office of Federal Contract Compliance Programs Instructions : Before completing this form, please read all instructions, including the Privacy Act statement below. Use thisOMB No.: 1215-0131 form to file a complaint of discrimination in employment under any of the OFCCP programs. Note: Persons are notExpires:1-31-08 required to respond to this collection of information unless it displays a currently valid OMB control number. P rivacy Act Notice: The authority for collecting this information is Executive Order 11246, as amended; Sec. 503 of the Rehabilitation Act of 1973, as amended; the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212; Title VII of the Civil R ights Act of 1964, as amended; and/or Title I of the Americans with Disabilities Act of 1990, as amended (ADA). This information is used to process complaints and conduct investigations of alleged violations of the above Order or Acts. We will provide a copy of this complaint to the employer against whom it is filed and, when matters alleged are covered by Title VII and/or the ADA, to the U.S. Equal Employment Opportunity Commission (EEOC). The information collected may be verified with others who may have knowledge relevant to the complaint. It may be used in settlement negotiations with the employer or in the course of presenting evidence at a hearing, or may be disclosed to other agencies with jurisdiction over the complaint. Providing this information is voluntary; however, failure to provide the information will restrict the action that the Department of Labor can take on your behalf and, for matters covered by Title VII or the ADA, may affect your right to sue under those laws. Non-Retaliation : OFCCP regulations, and Title VII and/or the ADA where applicable, require an employer to take all necessary steps to assure that there is no retaliation against any person who files a complaint or assists in its investigation.This includes any intimidation, threat, coercion or discrimination. Please notify OFCCP immediately if any alleged attempt at retaliation is made. Prom pt Filing : All complaints must befiled within a specified number of days following the latest occurrence of the alleged discrimination. Executive Order 11246 - 180 days; Rehabilitation and Veterans Acts - 300 days. Exceptions must be approved by the Deputy Assistant Secretary. Name and address: Mr. Ms. Mrs. Miss Name and address of company you allege discriminated againstyou Name Name Line #1 CityLine #1 City Line #2 State Z:ip Line #2 State Zip Telephone No. Telephone No. Mail this form to Dept. of L abor OFCCP Regional Office: Give date(s) of the latest occurrence(s) of the allegeddiscriminatory act(s):S tep 1:Check the box next to the program you are filing under (i.e., Executive Order 11246, as amended; Section 503 of the Rehabilitation Act of 1973, as amended, or the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212.) S tep 2:Under the program, check what you believe to be the basis for the discrimination against you, such as race, sex or national origin. If you think that there was more than one basis, more than one basis may be checked. You may also check more than one race/ethnic category. Executive Order 11246, as amended . This Order covers persons alleging discrimination because of race, color, religion, sex or national origin. If this is checked, your complaint will be dual-filed as a charge under Title VII of the Civil Rights Act of 1964. I believe I was (or continue to be) discriminated against because of my: Bases: Race Hispanic or Latino American Indian or Alaska Native Color Not Hispanic or Latino Asian Religion Black or African American Sex ( )Female ( ) Male Native Hawaiian or Other Pacific Islander National Origin White Other Se ction 503 of the Rehabilitation Ac t of 1973, as amended - This Act covers individuals with a disability, persons with a history of physical or mental disability, and persons regarded as disabledby the employer. If this is checked, your complaint will be dual-filed as a charge under the Americans with Disabilities Act. Basis: Disability Please check if you are a veteran . [] Yes [] No Viet nam Era Veterans Readjus t ment Assi s tanc e Ac t of 1974, as amended, 38 U.S.C. 4212. This Act covers special disabledveterans, veterans of the VietnamEra, and other protected veterans. Form CC-4 1 Rev. Sep 2004 American LegalNet, Inc. www.USCourtForms.com>>>> 2IF YOUR COMPLAINT IS BASED ON VETERAN STATUS, CHECK THE FOLLOWING APPLICABLE BOX(ES). I am entitled to disability compensation under laws administered by the Department of Veterans Affairs for a disability ratedat 30% or more; or rated at 10 or 20% and have been officially determined to have a serious employment disability. If you have checked this box, submit documentation from the Department of Veterans Affairs with this form. I was discharged or releasedfrom active duty for a service connected disability. If you have checked this box, submit medical information resulting in your discharge or release with this form. (This information is available from your Master MilitaryReco rd at the National Personnel Record Center, 9700 Page Blvd., St. Louis, MO 63132.) I served on activeduty for a period of more than 180 days, and wasdischarged or released with other than a dishonorable dischar ge, and the active duty occurred in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or between August 5, 1964, and May 7, 1975 in all other cases. I served on activeduty during a war or in a campaign or expedition for which a campaign badge has been authorized. ,ZDVGLVFKDUJHGRUUHOHDVHGIURPDFWLYHGXW\DQGP\GLVFKDUJHRUUHOHDVHGDWHLVQRHDUOLHUWKDQRQH\HDUSULRUWRWRGD\VGDte. S tep 3: Check those actions which you believe the employer took or failed to take because of your race, color, religion, sex, national origin, disability or veteran status (more than one may be checked): Iss ue(s ):  Hiring Promotion Job Assignment Accommodation to Disability Termination Demotion Training and Apprenticeship Sabbath Day Observance Layoff Seniority Segregated Facilities Intimidation Recall Harassme