Primary *

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary *

Yes

No

Phone *

Country

(###)

###

####

Primary *

Yes

No

Hire Date *

MM

DD

YYYY

On what basis is your employer discriminating against you? Check all that apply. *

Race

Color

Religion

Sex

Pregnancy

Age

Disability

National Origin

Ethnicity

Citizenship Status

Other

Do you think your employer retaliated against you? If yes, click the boxes below that apply. *

Opposing an unlawful discriminatory practice

Participating in an investigation or proceeding related to a complaint of unlawful discrimination

Requesting a reasonable accommodation based on disability under the ADA

Requesting a reasonable accommodation based on religion under Title VII

Requesting or taking a leave of absence under the FMLA

Engaging in “concerted activity” under the National Labor Relations Act (e.g., discussing wages, benefits, working conditions, hiring practices, employee discipline, or work assignments)

Whistleblowing (i.e., reporting an employer’s illegal conduct to an appropriate authority)

Other

Date of initial discriminatory or retaliatory action by Employer *

MM

DD

YYYY

Date of most recent complaint to Employer, if applicable *

MM

DD

YYYY

Do you have copies of the complaints made to company about adverse employment action *

Yes, I have copies of written complaints provided to company

No, I do not have any copies of written complaints provided to company

Complaints were verbal, not written

Did anyone witness the alleged unlawful conduct? *

Yes

No

Have you ever been placed on performance improvement plan, given corrective action, or otherwise disciplined by Employer *

Yes

No

Date of EEOC complaint, if applicable. *

MM

DD

YYYY

Have you received a right to sue letter from the EEOC? *

Yes

No

Have you been able to find a new job yet? *

Yes

No

Did you receive any treatment from a doctor or mental health provider as a result of the employer’s conduct? *

Yes

No

ACKNOWLEDGEMENT AND ACCEPTANCE *

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.