EEOC Charge of Discrimination

EEOC Charge of Discrimination

Worksheet and Preparation Template

U.S. Equal Employment Opportunity Commission
EEOC Form 5 (Charge of Discrimination)

IMPORTANT FILING DEADLINES:
- 180 calendar days from the last discriminatory act — states WITHOUT a Fair Employment Practices Agency (FEPA) or deferral agreement
- 300 calendar days from the last discriminatory act — states WITH a FEPA (deferral states; see Section 8 below for list)
- ADEA charges: Must be filed within the same 180/300-day periods (29 U.S.C. § 626(d))
- Equal Pay Act: No charge filing required before suit; 2-year statute (3 years for willful violations)
- For continuing violations (e.g., ongoing harassment): Deadline runs from the LAST act in the hostile environment pattern. National R.R. Passenger Corp. v. Morgan, 536 U.S. 101 (2002).

PART A — CHARGING PARTY INFORMATION

Full Legal Name: [________________________________]
Home Address: [________________________________]
City: [________________________________] State: [____] ZIP: [____]
Home Phone: [(___) ___-____] Cell Phone: [(___) ___-____]
Email Address (optional): [________________________________]
Date of Birth (ADEA claims — must be 40 or older): [__/__/____]

Preferred Contact Method: ☐ Mail ☐ Email ☐ Phone

PART B — EMPLOYER / RESPONDENT INFORMATION

Employer / Organization Name: [________________________________]
Street Address: [________________________________]
City: [________________________________] State: [____] ZIP: [____]
Phone: [(___) ___-____]
Number of Employees (approximate):
☐ Fewer than 15 ☐ 15–100 ☐ 101–200 ☐ 201–500 ☐ More than 500

Coverage Note: Title VII, ADA, and GINA apply to employers with 15 or more employees. ADEA applies to employers with 20 or more employees. Equal Pay Act applies to most employers regardless of size.

Type of Employer:
☐ Private employer ☐ State or local government ☐ Federal government agency
☐ Employment agency ☐ Labor organization ☐ Joint apprenticeship committee

HR Contact (if known): [________________________________]
Supervisor / Manager Name: [________________________________]

PART C — BASIS OF DISCRIMINATION (CHECK ALL THAT APPLY)

The discrimination I was subjected to was based on:

☐ Race — Specify: [________________________________]
☐ Color — Specify: [________________________________]
☐ National Origin — Specify: [________________________________]
☐ Religion — Specify: [________________________________]
☐ Sex (includes pregnancy, childbirth, related medical conditions, sexual orientation, gender identity per Bostock v. Clayton County, 590 U.S. 644 (2020))
☐ Sex / Gender
☐ Sexual Orientation (gay, lesbian, bisexual)
☐ Gender Identity / Transgender Status
☐ Pregnancy, Childbirth, or Related Medical Condition (Pregnancy Discrimination Act)
☐ Nursing / Lactation
☐ Age (40 or older — ADEA, 29 U.S.C. § 621 et seq.)
☐ Disability (physical or mental impairment substantially limiting a major life activity; or record of, or regarded as having such impairment — ADA Amendments Act of 2008)
— Describe disability: [________________________________]
— Major life activity affected: [________________________________]
☐ Genetic Information (GINA employment provisions, 42 U.S.C. § 2000ff et seq.)
☐ Equal Pay / Compensation Disparity (Equal Pay Act, 29 U.S.C. § 206(d))
☐ Pregnant Workers Fairness Act (PWFA) — denial of reasonable accommodation related to pregnancy, childbirth, or related medical conditions (effective June 27, 2023)
☐ Retaliation — for engaging in the following protected activity:
☐ Filing a prior EEOC charge or complaint
☐ Participating in an EEOC investigation or proceeding
☐ Opposing discrimination / reporting to HR or management
☐ Requesting a reasonable accommodation
☐ Other: [________________________________]
☐ Other: [________________________________]

PART D — TYPE OF DISCRIMINATORY ACTION (CHECK ALL THAT APPLY)

The discriminatory act(s) consisted of:

Adverse Employment Actions:
☐ Failure to hire / refusal to hire
☐ Demotion
☐ Wrongful termination / discharge
☐ Layoff / reduction in force
☐ Failure to promote
☐ Constructive discharge (forced to resign due to intolerable conditions)
☐ Reduction in pay, hours, or benefits
☐ Unequal pay for equal work
☐ Denial of training / development opportunities
☐ Unfavorable job assignment / transfer

Harassment / Hostile Work Environment:
☐ Sexual harassment — quid pro quo (conditioning employment benefit on sexual favor)
☐ Sexual harassment — hostile work environment (severe or pervasive unwelcome conduct based on sex)
☐ Racial / ethnic / national origin harassment
☐ Harassment based on religion, disability, age, or other protected characteristic
☐ Hostile work environment based on: [________________________________]

Accommodation-Related:
☐ Failure to provide reasonable accommodation for disability (ADA)
☐ Failure to engage in the interactive process (ADA)
☐ Failure to provide reasonable accommodation under the PWFA
☐ Failure to provide religious accommodation

Other:
☐ Discriminatory workplace policies or practices
☐ Discriminatory testing or pre-employment screening
☐ Retaliation (describe below)
☐ Other: [________________________________]

PART E — DATES OF DISCRIMINATION

Earliest date of discrimination: [__/__/____]
Most recent date of discrimination: [__/__/____]

☐ Continuing Violation — The discrimination is ongoing and has not yet ended. The most recent act occurred on [__/__/____].

Deadline Calculation (complete for attorney use):
- Date of last discriminatory act: [__/__/____]
- 180-day EEOC filing deadline: [__/__/____]
- 300-day deadline (deferral state): [__/__/____]
- State FEPA filing deadline: [__/__/____]
- Earliest deadline to file: [__/__/____]

PART F — STATEMENT OF HARM (FACTUAL NARRATIVE)

Describe the discrimination in detail. Include: your position and length of employment; the specific acts of discrimination; names and titles of persons involved; dates of key events; how similarly situated employees outside your protected class were treated differently; and the impact on your employment, pay, benefits, or working conditions. Attach additional pages as needed.

Position / Title: [________________________________]
Department: [________________________________]
Date of Hire: [__/__/____]
Date of Termination (if applicable): [__/__/____]
Annual Salary / Hourly Rate: $[____]

Narrative — What happened? Who did it? When? Where? How were you affected?

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Comparators (employees outside your protected class treated more favorably):

Witnesses:

Key Documents / Evidence:
☐ Performance reviews / evaluations
☐ Disciplinary notices
☐ Emails / text messages / written communications
☐ Medical documentation (disability accommodation claims)
☐ Pay stubs / compensation records
☐ Employee handbook / policies
☐ HR complaint records
☐ Other: [________________________________]

PART G — REASONABLE ACCOMMODATION REQUEST (DISABILITY / RELIGION / PWFA)

Complete if claim involves failure to accommodate.

Date accommodation was requested: [__/__/____]
Accommodation requested: [________________________________]
Employer's response: ☐ Granted ☐ Denied ☐ No response ☐ Proposed alternative: [________________________________]
Did employer engage in interactive process? ☐ Yes ☐ No ☐ Partially
Describe employer's stated reason for denial: [________________________________]
Did employer claim undue hardship? ☐ Yes ☐ No — Basis stated: [________________________________]

PART H — RELIEF SOUGHT

I am requesting the following relief (check all that apply):

☐ Reinstatement to former position
☐ Back pay (wages and benefits lost from [__/__/____] to present)
☐ Front pay (future lost earnings in lieu of reinstatement)
☐ Compensatory damages for emotional distress, pain and suffering
☐ Punitive damages (for intentional discrimination or reckless disregard)
☐ Reasonable accommodation / modification of policies
☐ Policy changes and/or anti-discrimination training
☐ Expungement of disciplinary record
☐ Reasonable attorney fees and costs
☐ Other: [________________________________]

Damages Caps (Title VII / ADA — combined compensatory + punitive):
- 15–100 employees: $50,000
- 101–200 employees: $100,000
- 201–500 employees: $200,000
- 500+ employees: $300,000
(No cap on back pay, front pay, or ADEA liquidated damages)

PART I — PRIOR PROCEEDINGS

Internal Complaint / HR Complaint:
☐ Yes — Filed with [________________________________] on [__/__/____]. Outcome: [________________________________]
☐ No

Union Grievance:
☐ Yes — Filed on [__/__/____]. Outcome: [________________________________]
☐ No — Not applicable

Prior EEOC or State Agency Charge:
☐ Yes — Charge No.: [________________________________] Filed: [__/__/____]
☐ No

State or Local Agency Filing (Dual Filing):
☐ Yes — Agency: [________________________________] Date: [__/__/____] Case No.: [________________________________]
☐ No — I request the EEOC cross-file this charge with the applicable state FEPA agency.

PART J — DEFERRAL STATE / DUAL-FILING REFERENCE

A 300-day Title VII deadline may apply when a qualifying state or local FEPA has jurisdiction over the statutory basis alleged; otherwise the ordinary 180-day route may apply. Check the claim, agency jurisdiction, receipt date, and current EEOC/FEPA filing protocol under 29 C.F.R. § 1601.13.

Note on Worksharing Agreements: Part 1601.13 governs EEOC filing and deferral; it does not itself establish an agreement with every FEPA or guarantee simultaneous filing. Confirm with both agencies whether an operative agreement covers this charge and obtain confirmation of each filing date.

PART K — REPRESENTATION

☐ I am represented by an attorney.

Attorney Name: [________________________________]
Firm: [________________________________]
Address: [________________________________]
Phone: [(___) ___-____]
Email: [________________________________]
Bar Number: [________________________________]

☐ I authorize the EEOC to communicate directly with my attorney regarding this charge.
☐ I am not represented by an attorney at this time.

PART L — RIGHT-TO-SUE LETTER REQUEST

☐ I request an immediate Notice of Right to Sue upon filing this charge.

Note: An EEOC charge must typically be pending for at least 180 days before a right-to-sue letter is issued on demand. However, if you need to file suit before 180 days have elapsed (e.g., due to an approaching statute of limitations), the EEOC may issue an early right-to-sue letter. Once issued, you have 90 days to file a lawsuit in federal court. 42 U.S.C. § 2000e-5(f)(1).

PART M — VERIFICATION AND SIGNATURE

I declare under penalty of perjury that I have read the above charge and that it is true to the best of my knowledge, information, and belief.

CHARGING PARTY SIGNATURE:

[________________________________]
Signature

[________________________________]
Printed Name

Date Signed: [__/__/____]

EEOC OFFICIAL USE ONLY:

Charge Number: [________________________________]
Date Filed: [__/__/____]
EEOC Office: [________________________________]
Investigator Assigned: [________________________________]
Intake Method: ☐ Online Portal ☐ In-Person ☐ Mail ☐ Phone Intake

FILING INSTRUCTIONS

How to File This Charge:

1. Online: Submit via the EEOC Public Portal at publicportal.eeoc.gov (preferred method — creates charge immediately and allows document uploads).
2. In-Person: Visit your nearest EEOC field office. Locate offices at www.eeoc.gov/field-office.
3. Mail: Send to the EEOC office with jurisdiction over your employer's location.
4. Phone Intake: Call 1-800-669-4000 (voice) or 1-800-669-6820 (TTY) to schedule an intake interview.

Documents to Bring / Attach:
☐ Copy of this completed worksheet
☐ Performance evaluations / disciplinary records
☐ Written communications (emails, texts, letters)
☐ Medical documentation (if disability claim)
☐ Pay records (if compensation claim)
☐ Termination letter / notice (if applicable)

Attorney's Note: This worksheet is a preparation tool. The official charge is EEOC Form 5, signed by the charging party. An unsigned or unsworn document does not constitute a charge for timeliness purposes. Charges must be filed timely regardless of whether mediation or internal resolution is pending.