AMERICANS WITH DISABILITIES ACT (ADA) EMPLOYMENT DISCRIMINATION COMPLAINT

EEOC Administrative Charge Template

SECTION 1: CHARGE INFORMATION

Charge Presented To:
☐ EEOC (Equal Employment Opportunity Commission)
☐ State/Local FEPA: _____________________________________________________

EEOC Office Location: _________________________________________________

Date of Filing: ________________________________________________________

SECTION 2: COMPLAINANT INFORMATION

Full Legal Name: _____________________________________________________

Street Address: _______________________________________________________

City: _________________________ State: _________ Zip Code: __________

Home Phone: _________________________ Cell Phone: ___________________

Email Address: ________________________________________________________

Date of Birth: _________________________________________________________

SECTION 3: RESPONDENT/EMPLOYER INFORMATION

Company Legal Name: _________________________________________________

Street Address: _______________________________________________________

City: _________________________ State: _________ Zip Code: __________

Phone Number: _______________________________________________________

Number of Employees: _________________________________________________

☐ 15 or more employees (required for ADA coverage)

Industry/Type of Business: ______________________________________________

SECTION 4: EMPLOYMENT INFORMATION

Job Title: ____________________________________________________________

Department: __________________________________________________________

Date of Hire: _________________________________________________________

Employment Status:
☐ Full-time ☐ Part-time ☐ Temporary ☐ Applicant (not hired)

Current Status:
☐ Currently Employed
☐ Terminated - Date: _____________________________________________________
☐ Resigned - Date: _______________________________________________________
☐ On Leave - Date: ______________________________________________________

Supervisor Name and Title: _____________________________________________

SECTION 5: DISABILITY INFORMATION

A. Nature of Disability

Type of Disability:
☐ Physical disability
☐ Mental/psychological disability
☐ Chronic health condition
☐ Record of disability (history of impairment)
☐ Regarded as having a disability

Description of Disability/Medical Condition:

___________________________________________________________________________

___________________________________________________________________________

Date of Diagnosis (if applicable): _________________________________________

Does this condition substantially limit one or more major life activities?
☐ Yes ☐ No

Major Life Activities Affected:
☐ Walking
☐ Standing
☐ Sitting
☐ Lifting
☐ Seeing
☐ Hearing
☐ Speaking
☐ Breathing
☐ Learning
☐ Concentrating
☐ Thinking
☐ Communicating
☐ Working
☐ Sleeping
☐ Eating
☐ Bending
☐ Reading
☐ Performing manual tasks
☐ Caring for oneself
☐ Major bodily functions (specify): __________________________________________
☐ Other: ________________________________________________________________

B. Medical Documentation

Have you provided medical documentation to your employer?
☐ Yes ☐ No

If yes:
Date(s) Provided: _____________________________________________________

Type of Documentation: ________________________________________________

To Whom: ____________________________________________________________

SECTION 6: TYPE OF ADA DISCRIMINATION CLAIM

Check all that apply:

Failure to Provide Reasonable Accommodation

☐ Employer refused to provide a reasonable accommodation
☐ Employer failed to engage in the interactive process
☐ Employer claimed undue hardship without proper justification
☐ Employer retaliated after I requested an accommodation

Disparate Treatment Based on Disability

☐ I was treated differently because of my disability
☐ I was subjected to adverse employment action because of my disability

Failure to Hire

☐ I was not hired because of my disability
☐ I was not hired because I was perceived as having a disability

Wrongful Termination

☐ I was terminated because of my disability
☐ I was terminated after requesting an accommodation
☐ I was terminated after returning from disability-related leave

Harassment Based on Disability

☐ I was harassed because of my disability
☐ The harassment created a hostile work environment

Medical Examination/Inquiry Violations

☐ I was subjected to unlawful pre-employment medical inquiries
☐ I was subjected to unlawful medical examination
☐ My medical information was improperly disclosed

Retaliation

☐ I was retaliated against for requesting an accommodation
☐ I was retaliated against for filing a complaint
☐ I was retaliated against for opposing disability discrimination

SECTION 7: ESSENTIAL JOB FUNCTIONS

What are the essential functions of your job?

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

5. ________________________________________________________________________

Can you perform these essential functions?
☐ Yes, without any accommodation
☐ Yes, with reasonable accommodation
☐ Some functions, with accommodation

If accommodation is needed, explain:

___________________________________________________________________________

___________________________________________________________________________

SECTION 8: REASONABLE ACCOMMODATION REQUEST

A. Accommodation Requested

Date of Request: ______________________________________________________

How Was the Request Made?
☐ Verbal ☐ Written ☐ Email ☐ Through HR ☐ Through supervisor

To Whom Did You Make the Request?

Name: __________________________________________________________________

Title: ___________________________________________________________________

What Accommodation Did You Request?

☐ Modified work schedule
☐ Work from home/telework
☐ Additional breaks
☐ Reassignment to vacant position
☐ Leave of absence
☐ Modified job duties
☐ Ergonomic equipment
☐ Assistive technology
☐ Physical modifications to workspace
☐ Policy modification
☐ Job restructuring
☐ Interpreter/reader services
☐ Other: ________________________________________________________________

Specific Description of Accommodation Requested:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

B. Employer's Response

Did the employer engage in the interactive process?
☐ Yes ☐ No ☐ Partially

If yes, describe the interactive process:

___________________________________________________________________________

___________________________________________________________________________

Employer's Decision:
☐ Accommodation granted
☐ Accommodation denied
☐ Alternative accommodation offered
☐ No response provided
☐ Delayed response

Date of Decision: _____________________________________________________

Reason Given for Denial (if applicable):

☐ Undue hardship claimed
☐ Not qualified for position
☐ No accommodation needed
☐ Accommodation would change essential functions
☐ Direct threat to safety
☐ No reason given
☐ Other: ________________________________________________________________

Employer's Stated Explanation:

___________________________________________________________________________

___________________________________________________________________________

C. Alternative Accommodations

Were alternative accommodations discussed?
☐ Yes ☐ No

If yes, describe:

___________________________________________________________________________

Would an alternative accommodation have been effective?
☐ Yes ☐ No

Explain: _________________________________________________________________

SECTION 9: DATES OF DISCRIMINATION

Date Discrimination First Occurred: _______________________________________

Date of Most Recent Discriminatory Act: ___________________________________

Is the Discrimination Continuing? ☐ Yes ☐ No

SECTION 10: DETAILED STATEMENT OF FACTS (PARTICULARS)

Describe in detail what happened. Include WHO, WHAT, WHEN, WHERE, and WHY you believe it was discrimination based on disability.

A. Background

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

B. Chronology of Events

Event 1:

Date: ___________________________________________________________________

Persons Involved: _________________________________________________________

What Happened:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Event 2:

Date: ___________________________________________________________________

Persons Involved: _________________________________________________________

What Happened:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Event 3:

Date: ___________________________________________________________________

Persons Involved: _________________________________________________________

What Happened:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

(Attach additional pages if necessary)

C. How Were You Harmed?

___________________________________________________________________________

___________________________________________________________________________

D. Why Do You Believe This Was Disability Discrimination?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

SECTION 11: COMPARATIVE TREATMENT

Were non-disabled employees treated differently in similar circumstances?
☐ Yes ☐ No

If yes:

SECTION 12: WITNESSES

SECTION 13: EVIDENCE

Documents You Have:
☐ Accommodation request (written)
☐ Employer's response to accommodation request
☐ Medical documentation
☐ Performance evaluations
☐ Emails or correspondence
☐ Termination letter
☐ Job description
☐ Witness statements
☐ Other: ________________________________________________________________

SECTION 14: STATE-SPECIFIC NOTES

California

• Additional State Protections: California Fair Employment and Housing Act (FEHA), Government Code § 12940
• Broader Definition: FEHA uses "limits" rather than "substantially limits" a major life activity
• Interactive Process: California requires employers to engage in a timely, good faith interactive process
• Filing Deadline: 3 years to file with California Civil Rights Department
• Lower Employee Threshold: FEHA applies to employers with 5+ employees

Texas

• State Law: Texas Labor Code Chapter 21 provides parallel protections
• Filing Deadline: 180 days to file with Texas Workforce Commission
• Employer Coverage: 15+ employees

Florida

• State Law: Florida Civil Rights Act, Florida Statutes § 760.10
• Filing Deadline: 365 days to file with Florida Commission on Human Relations
• Employer Coverage: 15+ employees

New York

• State Law: New York State Human Rights Law, Executive Law § 296
• Broader Protections: New York law is broader than federal ADA
• Filing Deadline: 3 years to file with NY Division of Human Rights (as of 2/15/2024)
• Employer Coverage: 4+ employees
• NYC: Additional protections under NYC Human Rights Law

SECTION 15: ADA KEY LEGAL STANDARDS

Qualified Individual with a Disability

Under the ADA, a "qualified individual" is a person who:
1. Has a physical or mental impairment that substantially limits one or more major life activities, OR
2. Has a record of such an impairment, OR
3. Is regarded as having such an impairment

AND can perform the essential functions of the job with or without reasonable accommodation.

Reasonable Accommodation

Examples include:
- Making facilities accessible
- Job restructuring
- Part-time or modified schedules
- Acquiring or modifying equipment
- Providing qualified readers or interpreters
- Reassignment to vacant position
- Leave for treatment

Undue Hardship

An employer need not provide an accommodation that would cause "undue hardship" - significant difficulty or expense considering:
- Nature and cost of accommodation
- Overall financial resources of the facility and employer
- Type of operation
- Impact on operations

Direct Threat Defense

An employer may refuse to hire or may terminate an individual who poses a "direct threat" - a significant risk of substantial harm to self or others that cannot be eliminated or reduced by reasonable accommodation.

SECTION 16: RELIEF REQUESTED

☐ Back pay
☐ Front pay
☐ Reinstatement
☐ Reasonable accommodation
☐ Compensatory damages (emotional distress)
☐ Punitive damages
☐ Attorney's fees and costs
☐ Policy changes at employer
☐ Training for management
☐ Removal of negative information from personnel file
☐ Other: ________________________________________________________________

SECTION 17: VERIFICATION AND SIGNATURE

I declare under penalty of perjury that the information provided in this charge is true and correct to the best of my knowledge, information, and belief.

I understand that:
- The ADA prohibits discrimination against qualified individuals with disabilities
- I must cooperate with the EEOC investigation
- Filing this charge protects my right to file a lawsuit if necessary

Signature: ____________________________________________________________

Printed Name: _________________________________________________________

Date: ________________________________________________________________

SECTION 18: FILING DEADLINES REMINDER

ATTACHMENT CHECKLIST

☐ Medical documentation (as appropriate)
☐ Written accommodation request
☐ Employer's response to accommodation request
☐ Correspondence related to the interactive process
☐ Job description
☐ Performance evaluations
☐ Disciplinary records
☐ Termination documentation
☐ Witness contact information
☐ Additional pages for detailed statement

This complaint template is designed for filing disability discrimination charges with the EEOC. For filing a federal court complaint after receiving a Right to Sue letter, additional requirements apply under the Federal Rules of Civil Procedure.