EEOC INTAKE QUESTIONNAIRE

Pre-Charge Employment Discrimination Inquiry

PRIVACY ACT STATEMENT

This questionnaire is covered by the Privacy Act of 1974, Public Law 93-579. The information requested is voluntary; however, providing complete information helps EEOC determine whether it has jurisdiction over your claim and how to properly handle your matter.

IMPORTANT: Submitting this questionnaire does NOT constitute filing a formal charge of discrimination. A formal charge must be filed separately within applicable time limits.

PART 1: YOUR INFORMATION

A. Personal Information

Full Legal Name: _____________________________________________________

Former/Maiden Name (if applicable): _____________________________________

Date of Birth: ________________________________________________________

Social Security Number (last 4 digits only): XXX-XX-____

B. Contact Information

Current Street Address: ________________________________________________

City: _________________________ State: _________ Zip Code: __________

Mailing Address (if different): ___________________________________________

Home Phone: _________________________________________________________

Cell Phone: __________________________________________________________

Work Phone (if safe to contact): _________________________________________

Email Address: ________________________________________________________

Preferred Contact Method:
☐ Home Phone ☐ Cell Phone ☐ Work Phone ☐ Email ☐ Mail

Best Times to Contact: _________________________________________________

May we leave a voicemail message? ☐ Yes ☐ No

C. Demographic Information (Voluntary)

This information is used for statistical purposes only and will not affect processing of your inquiry.

Race/Ethnicity:
☐ American Indian or Alaska Native
☐ Asian
☐ Black or African American
☐ Hispanic or Latino
☐ Native Hawaiian or Other Pacific Islander
☐ White
☐ Two or More Races
☐ Prefer not to answer

Gender:
☐ Male ☐ Female ☐ Non-binary ☐ Prefer not to answer

Do you have a disability?
☐ Yes ☐ No ☐ Prefer not to answer

PART 2: EMPLOYER INFORMATION

A. Primary Employer/Organization

Name of Company/Organization: _________________________________________

Type of Employer:
☐ Private Company
☐ State Government
☐ Local Government
☐ Federal Government
☐ Labor Union
☐ Employment Agency
☐ Joint Apprenticeship Committee
☐ Other: _______________________________________________________________

Street Address: _______________________________________________________

City: _________________________ State: _________ Zip Code: __________

Main Phone Number: __________________________________________________

Website (if known): ____________________________________________________

B. Employer Size

Approximate Number of Employees at Your Location: _________________________

Approximate Total Number of Employees (all locations): _______________________

☐ Fewer than 15 employees
☐ 15-19 employees
☐ 20-100 employees
☐ 101-200 employees
☐ 201-500 employees
☐ More than 500 employees
☐ Unknown

C. Human Resources Contact

HR Representative Name: _______________________________________________

HR Phone Number: ____________________________________________________

HR Email: ____________________________________________________________

D. Additional Employers/Entities Involved (if applicable)

Name: _______________________________________________________________

Relationship to Primary Employer: ________________________________________

Address: _____________________________________________________________

PART 3: YOUR EMPLOYMENT

A. Employment Details

Your Job Title: ________________________________________________________

Department: __________________________________________________________

Location Where You Worked: ____________________________________________

Date You Started Working: ______________________________________________

Are You Currently Employed There? ☐ Yes ☐ No

If No, Last Day Worked: ________________________________________________

Reason for Separation:
☐ Fired/Terminated
☐ Laid Off
☐ Resigned
☐ Constructive Discharge (forced to quit)
☐ Contract Ended
☐ Still Employed
☐ Other: _______________________________________________________________

B. Compensation

Pay Rate: $ _____________ per ☐ Hour ☐ Week ☐ Month ☐ Year

Pay Type: ☐ Exempt (Salary) ☐ Non-Exempt (Hourly)

Work Schedule: _______ hours per week

C. Supervisory Chain

Immediate Supervisor Name: ____________________________________________

Supervisor Title: ______________________________________________________

Supervisor Phone/Email: ________________________________________________

Next Level Manager: ___________________________________________________

PART 4: DISCRIMINATION ALLEGATIONS

A. Basis of Discrimination

The laws enforced by EEOC prohibit discrimination based on certain protected characteristics. Check ALL that apply to your situation:

Race Discrimination
☐ I was treated differently because of my race
My race: _______________________________________________________________

Color Discrimination
☐ I was treated differently because of my skin color

National Origin Discrimination
☐ I was treated differently because of my national origin or ancestry
My national origin: _______________________________________________________

Sex/Gender Discrimination
☐ I was treated differently because of my sex/gender
☐ Sexual harassment
☐ Pregnancy discrimination
☐ LGBTQ+ discrimination (sexual orientation or gender identity)

Religious Discrimination
☐ I was treated differently because of my religion
☐ I was denied a religious accommodation
My religion: _____________________________________________________________

Age Discrimination
☐ I was treated differently because of my age (I am 40 or older)
My age/date of birth: _____________________________________________________

Disability Discrimination
☐ I was treated differently because of my disability
☐ I was denied a reasonable accommodation
☐ I was subjected to improper medical inquiries
My disability: ____________________________________________________________

Genetic Information
☐ I was treated differently because of genetic information or family medical history

Retaliation
☐ I was retaliated against for:
☐ Filing a discrimination complaint
☐ Opposing discriminatory practices
☐ Participating in an investigation
☐ Being a witness in a discrimination case
☐ Requesting an accommodation

Equal Pay
☐ I am paid less than employees of the opposite sex for equal work

B. Type of Harm

What action(s) did the employer take that you believe was discriminatory? Check ALL that apply:

☐ Did not hire me
☐ Fired/terminated me
☐ Did not promote me
☐ Demoted me
☐ Suspended me
☐ Disciplined me unfairly
☐ Gave me a poor performance evaluation
☐ Reduced my pay or hours
☐ Denied me benefits
☐ Denied me training opportunities
☐ Assigned me to less desirable duties
☐ Harassed me
☐ Created a hostile work environment
☐ Denied my request for accommodation
☐ Denied my request for leave
☐ Gave me an unfavorable reference
☐ Forced me to resign
☐ Other: _______________________________________________________________

C. Timeline of Events

When did the discrimination first occur?

Date: _________________________________________________________________

When did the most recent discriminatory act occur?

Date: _________________________________________________________________

Is the discrimination ongoing? ☐ Yes ☐ No

PART 5: DETAILED DESCRIPTION OF EVENTS

Please describe what happened to you. Be as specific as possible, including WHO, WHAT, WHEN, WHERE, and WHY. Use additional pages if necessary.

What Happened?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Who Was Involved?

List the names, titles, and roles of the people who discriminated against you:

Why Do You Believe This Was Discrimination?

Explain why you believe the treatment was based on your protected characteristic(s):

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Comparative Treatment

Were other employees treated differently than you in similar situations? Describe:

Name of Comparator: ___________________________________________________

Their Protected Characteristic: ___________________________________________

How Were They Treated Differently?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

PART 6: WITNESSES

List anyone who witnessed the discrimination or has relevant information:

PART 7: EVIDENCE

What evidence do you have to support your claim? Check all that apply:

☐ Written documents (emails, letters, memos)
☐ Text messages
☐ Voicemails
☐ Performance evaluations
☐ Policies or handbooks
☐ Photographs
☐ Video or audio recordings
☐ Medical records
☐ Pay records
☐ Witness statements
☐ Other: _______________________________________________________________

Briefly describe the evidence you have:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

PART 8: PRIOR COMPLAINTS

A. Internal Complaints

Did you complain to anyone at your company? ☐ Yes ☐ No

If yes:

To Whom? ____________________________________________________________

Date(s): ______________________________________________________________

How (verbally, in writing, HR hotline)? _____________________________________

What Response Did You Receive?

___________________________________________________________________________

___________________________________________________________________________

B. Union Grievance

Are you a member of a union? ☐ Yes ☐ No

Did you file a grievance? ☐ Yes ☐ No

Union Name: __________________________________________________________

Grievance Status: ______________________________________________________

C. Other Agency Complaints

Have you filed a complaint with any other agency or court? ☐ Yes ☐ No

If yes:

PART 9: REPRESENTATION

Do you have an attorney? ☐ Yes ☐ No

If yes:

Attorney Name: ________________________________________________________

Law Firm: _____________________________________________________________

Phone: _______________________________________________________________

Email: ________________________________________________________________

May we contact your attorney directly? ☐ Yes ☐ No

PART 10: DAMAGES AND RELIEF

A. Economic Damages

Lost Wages (estimate): $ _______________________________________________

Lost Benefits (estimate): $ ______________________________________________

Out-of-Pocket Expenses: $ ______________________________________________

Other Financial Losses: $ _______________________________________________

B. Non-Economic Damages

Describe any emotional or physical harm you have suffered:

___________________________________________________________________________

___________________________________________________________________________

☐ I have sought medical or mental health treatment related to this discrimination

C. What Do You Want to Happen?

Check all remedies you are seeking:

☐ Get my job back
☐ Get the promotion I was denied
☐ Receive back pay
☐ Receive front pay (future lost wages)
☐ Receive compensatory damages for emotional distress
☐ Have the company change its policies
☐ Have the harasser disciplined or fired
☐ Have negative information removed from my personnel file
☐ Receive a neutral or positive reference
☐ Other: _______________________________________________________________

PART 11: STATE-SPECIFIC INFORMATION

California Residents

☐ I wish to file with the California Civil Rights Department (CRD)
- State deadline: 3 years from discriminatory act
- CRD can issue immediate right-to-sue upon request
- California FEHA provides additional protections

Texas Residents

☐ I wish to file with the Texas Workforce Commission Civil Rights Division (TWC-CRD)
- State deadline: 180 days from discriminatory act
- Dual filing with EEOC is automatic
- Filing must be done online, by email, or by mail (not by phone)

Florida Residents

☐ I wish to file with the Florida Commission on Human Relations (FCHR)
- State deadline: 365 days from discriminatory act
- Florida law includes marital status protection
- If FCHR does not complete investigation within 180 days, may proceed to court

New York Residents

☐ I wish to file with the New York State Division of Human Rights (DHR)
- State deadline: 3 years from discriminatory act (effective February 15, 2024)
- New York provides broader protected class coverage
- NYC residents may also file with NYC Commission on Human Rights

PART 12: IMPORTANT DEADLINES

Federal Filing Deadlines (EEOC)

Don't Lose Your Rights

☐ I understand that I must file a formal charge within the applicable deadline
☐ I understand that completing this questionnaire does NOT constitute filing a charge
☐ I understand that deadlines are strictly enforced and cannot usually be extended

Today's Date: _________________________________________________________

Date of Most Recent Discriminatory Act: ___________________________________

Days Remaining to File (300-day deadline): _________________________________

PART 13: SIGNATURE AND VERIFICATION

I declare that the information provided in this questionnaire is true and accurate to the best of my knowledge. I understand that providing false information may have legal consequences.

I understand that:
- This questionnaire is for intake purposes only
- Filing this questionnaire does NOT file a formal charge
- I must take additional steps to file a formal charge
- Filing deadlines continue to run until a formal charge is filed

Signature: ____________________________________________________________

Printed Name: _________________________________________________________

Date: ________________________________________________________________

NEXT STEPS

After completing this questionnaire:

1. Submit to EEOC: Bring or mail to your local EEOC office, or submit online through the EEOC Public Portal at https://publicportal.eeoc.gov

2. EEOC Contact: Within 30 days, an EEOC representative should contact you

3. Interview: You may be scheduled for an interview to discuss your allegations

4. Formal Charge: If appropriate, you will be assisted in filing a formal Charge of Discrimination

5. Keep Copies: Retain copies of everything you submit

CHECKLIST OF DOCUMENTS TO GATHER

☐ Employment contract or offer letter
☐ Employee handbook
☐ Performance evaluations
☐ Disciplinary notices
☐ Termination letter
☐ Pay stubs
☐ Emails and correspondence
☐ Text messages
☐ Photos of evidence
☐ Medical records (if relevant)
☐ Prior complaint documents
☐ Witness contact information

For assistance, contact your local EEOC field office or visit www.eeoc.gov. The EEOC can be reached at 1-800-669-4000 (TTY: 1-800-669-6820).