North Dakota Employment Discrimination Intake Preparation Worksheet
NORTH DAKOTA EMPLOYMENT DISCRIMINATION INTAKE PREPARATION WORKSHEET
Before you use this: The North Dakota Department of Labor and Human Rights provides an online employment-discrimination intake and a paper questionnaire/affidavit. Its paper form must be signed. This private worksheet helps you organize facts before completing the official form; do not submit it as a charge.
For an employment claim under N.D. Cent. Code § 14-02.4-19(2), the Department's current guidance says to file no later than 300 days from the last date of harm. Record each event date now. Section 14-02.4-23(1) requires an agency complaint to be in writing and in the form the Department prescribes. Check any separate federal or other deadline independently.
1. People and workplace
Your name and preferred contact information: [________________________________]
Employer's legal name, worksite, and contact information: [________________________________]
Your position, main duties, and employment dates: [________________________________]
Current status: ☐ Applicant ☐ Employed ☐ Former employee ☐ Other [________________________________]
People who made or communicated the decisions at issue: [________________________________]
Have you filed about these events with another agency? ☐ No ☐ Yes; agency, date, and case number: [________________________________]
2. What happened
| Event date | Decision or conduct | Person involved | Record or witness |
|---|---|---|---|
| [__/__/____] | [FACTS] | [NAME] | [RECORD / WITNESS] |
| [__/__/____] | [FACTS] | [NAME] | [RECORD / WITNESS] |
Last date of alleged harm: [__/__/____]
What characteristic, protected activity, or accommodation request do you believe was involved, and why? [________________________________]
How were you affected in hiring, work conditions, pay, promotion, accommodation, discipline, or separation? [________________________________]
What explanation did the employer give, if any? [________________________________]
Other employees or applicants treated differently, if known: [________________________________]
3. Records and requested resolution
Internal complaint or grievance, if any, with date and response: [________________________________]
Witnesses and how they know the facts: [________________________________]
Records to locate: ☐ messages ☐ job posting or application ☐ reviews ☐ pay records ☐ policy ☐ accommodation correspondence ☐ other [________________________________]
Resolution you would seek: [________________________________]
4. Complete the Department's intake
☐ Use the Department's online form or its current paper form, SFN 14543. Answer its questions and attach a factual statement and evidence it requests. The paper form instructs you to sign it before submission.
☐ Review the official form's certification before signing. Provide sensitive medical or other personal records only through the official agency route as the form directs.
☐ Save a copy of the signed submission and its delivery confirmation. The Department's guidance says it will contact a submitter after review and determine whether it has jurisdiction.
Submission date, method, and confirmation: [________________________________]
Official sources
About this template
- Last updated
- October 27, 2026
- Citations checked
- October 27, 2026
- Jurisdiction
- North Dakota
- Category
- Civil Rights
Legal authority
- N.D. Cent. Code § 14-02.4-19(2)
- N.D. Cent. Code § 14-02.4-23(1)
Civil rights cases address violations of your constitutional or federally protected rights by government officials, employers, landlords, or businesses. Most of these claims come with short deadlines and specific filing requirements. Well-drafted complaints and demand letters identify the right law, name the right parties, and preserve your claims before the clock runs out.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on October 27, 2026.
N.D. Cent. Code § 14-02.4-19(2) (checked October 27, 2026): "Any person claiming to be aggrieved by any discriminatory practice other than public services or public accommodations in violation of this chapter may file a complaint of discriminatory practice with the department or, except as limited by this section, may bring an action in the district court in the judicial district in which the unlawful practice is alleged to have been committed, in the district in which the records relevant to the practice are maintained and administered, or in the district in which the person would Page No. 6 have worked or obtained credit were it not for the alleged discriminatory act within three hundred days of the alleged act of wrongdoing."
N.D. Cent. Code § 14-02.4-23(1) (checked October 27, 2026): "A complaint must be in writing and in the form prescribed by the department."
North Dakota Department of Labor and Human Rights, Equal Employment Opportunity Questionnaire/Affidavit, SFN 14543 (checked October 27, 2026): "This complaint form and accompanying statements must be signed in order to process a charge of discrimination."
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