File an Employment Discrimination Complaint

1. Enter information about yourself.

First Name:

Last Name:

Address:

City:

State:

Zip:

Home Phone:

Mobile Phone:

Work Phone:

E-Mail Address:

Best time to contact you:

Who else can we contact if we cannot reach you?

Contact's Name:

Contact's Phone:

Relationship to You:

2. Who was discriminated against?

Yourself

Someone Else

NOTE: If the person discriminated against is 18 or older, we will need that person’s signature before we can proceed with this complaint.

If someone other than yourself, please include:

Injured person’s name:

Relationship to you:

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

3. When did the alleged discrimination occur?

Date of occurrance:

4. Name of organization or agency that discriminated against you.

Organization/Agency Name:

Address:

County:

City:

State:

Zip:

Primary Phone:

Alternate Phone:

Name of Person(s) who discriminated against you:

1. Name:

Position/title:

2. Name:

Position/title:

3. Name:

Position/title:

How many employees does your business have?

4-14

15-20

21+

Date of Birth

I have filed my complaint with the EEOC

Date Filed with EEOC

What is the status of the EEOC complaint?

5. In the space provided below, please briefly describe each discriminatory action separately.

For each action, you need to provide the following information:

a. Date (s) the discriminatory action occurred;
b. Name(s) of individual(s) who discriminated (include position, title);
c. What happened;
d. Witnesses, (if any);
e. Why you believe the discrimination was because of the reason you indicated above, or why you believe the action was retalitory.

Do you have documents that you think will help us understand your complaint? (If yes, you will be contacted with instructions for submitting this information. Do not send original documents.)

Yes

No

6. What solution are you seeking?

Human Rights and Equity Programs

Human Rights and Equity Programs Alert:

Department Resources

Fairfax Virtual Assistant

Human Rights and Equity Programs

Human Rights and Equity Programs Alert:

Department Resources

File an Employment Discrimination Complaint

Details if submitting for someone else

Fairfax Virtual Assistant