North Dakota Employment Discrimination Questionnaire/Affidavit — SFN 14543 Drafting Companion

EMPLOYMENT DISCRIMINATION QUESTIONNAIRE/AFFIDAVIT — NORTH DAKOTA

Drafting companion to current official SFN 14543 (11-2021). Transfer the completed information to the Department's current online intake or current signed official form. Do not submit this drafting companion in place of the official form unless the Department confirms it will accept it.

To: North Dakota Department of Labor and Human Rights

600 East Boulevard Avenue, Dept. 406

Bismarck, ND 58505-0340

Telephone: (701) 328-2660 / Toll-Free 1-800-582-8032

Fax: (701) 328-2031 / Relay ND TTY: 1-800-366-6888 or 1-800-366-6889

Web: https://www.nd.gov/labor

Federal coordination: The Department is a Fair Employment Practice Agency in the EEOC Minneapolis Area Office's territory. If federal law applies, the agencies' dual-filing process may protect both state and federal claims; confirm receipt and coverage rather than assuming every state charge satisfies every federal requirement.

TABLE OF CONTENTS

1. Charging Party Information
2. Respondent Information
3. Bases of Discrimination
4. Issues / Adverse Actions
5. Date(s) of Discrimination
6. Statement of Particulars (Narrative)
7. Witnesses and Comparators
8. Documents Submitted
9. Requested Resolution
10. Other Proceedings and Filing Review
11. Affidavit and Signature
12. Practice Notes — North Dakota DLHR Procedure
13. Sources and References

1. CHARGING PARTY INFORMATION

2. RESPONDENT INFORMATION

3. BASES OF DISCRIMINATION

I believe I was discriminated against because of (check all that apply):

• ☐ Race — specify: [__________]
• ☐ Color — specify: [__________]
• ☐ Religion — specify: [__________]
• ☐ Sex — including (check if applicable): ☐ Pregnancy ☐ Sexual Harassment ☐ Sexual Orientation ☐ Gender Identity ☐ Sex Stereotyping
• ☐ National Origin — specify: [__________]
• ☐ Age (40+) — date of birth: [__/__/____]
• ☐ Disability (mental or physical) — specify: [__________]
• ☐ Marital Status — specify: [__________]
• ☐ Status with regard to Public Assistance
• ☐ Lawful off-duty activity — specify: [__________]
• ☐ Retaliation for protected activity (N.D.C.C. § 14-02.4-18)
• ☐ Other employment basis — identify the law and confirm that the Department or EEOC accepts it: [__________]

The current official SFN 14543 lists sexual orientation, gender identity, and sex stereotyping under sex. Those labels are not separately enumerated in the current NDHRA employment-class text; preserve and separately identify any federal Title VII theory where applicable.

4. ISSUES / ADVERSE ACTIONS

The discriminatory act(s) included (check all that apply):

• ☐ Failure to hire
• ☐ Discharge / Termination
• ☐ Constructive discharge
• ☐ Layoff / Reduction in force
• ☐ Demotion
• ☐ Denial of promotion
• ☐ Discipline / Written warning / Suspension
• ☐ Harassment / Hostile work environment
• ☐ Sexual harassment
• ☐ Disparate pay / wages
• ☐ Denial of benefits
• ☐ Denial of reasonable accommodation (disability / religion / pregnancy)
• ☐ Different terms and conditions of employment
• ☐ Retaliation for protected activity
• ☐ Other: [__________]

This packet is for employment discrimination. Housing, public-accommodation, public-service, credit, wage-hour, general whistleblower, and federal-sector EEO matters use different forms, statutes, or procedures.

5. DATE(S) OF DISCRIMINATION

File as soon as possible. The Department's current employment page and N.D.C.C. § 14-02.4-19(2) use a 300-day outside period for an employment complaint, but federal coverage and timing may differ. Do not wait for an internal process, investigation, or settlement discussion to calculate and preserve every applicable deadline.

6. STATEMENT OF PARTICULARS (NARRATIVE)

I, [CHARGING PARTY NAME], allege the following facts in support of this Charge of Discrimination:

A. My Background and Employment

6.1. I was hired by Respondent on [__/__/____] as a [POSITION]. Throughout my employment, I performed my job satisfactorily, met or exceeded expectations, and received [PERFORMANCE EVALUATIONS / COMMENDATIONS / RAISES].

6.2. I rely on the following checked basis or bases: [DESCRIBE THE BASIS AND SUPPORTING FACTS; DO NOT RELY ON LABELS ALONE].

B. The Discriminatory Conduct

6.3. On or about [__/__/____], the following occurred: [DESCRIBE FIRST INCIDENT — who, what, where, when, how].

6.4. On or about [__/__/____], [DESCRIBE SECOND INCIDENT].

6.5. On or about [__/__/____] (the "Last Date of Harm"), Respondent [DESCRIBE FINAL ADVERSE ACTION — termination, demotion, denial of accommodation, etc.].

C. Comparators / Similarly Situated Employees Treated More Favorably

6.6. [IF KNOWN] The following employees were treated differently in comparable circumstances: [NAME / POSITION / RELEVANT SIMILARITIES / DIFFERENT TREATMENT].

D. Pretext

6.7. Respondent stated that it acted because [STATED REASON]. The facts that bear on whether that explanation is accurate are: [DOCUMENTS, TIMING, COMPARATORS, CHANGING EXPLANATIONS, OR OTHER FACTS].

E. Reasonable Accommodation (if applicable)

6.8. On [__/__/____], I requested the following accommodation for [DISABILITY / RELIGION / PREGNANCY]: [DESCRIBE]. Respondent answered or acted as follows: [DESCRIBE, WITH DATES]. Facts showing I could perform the essential functions and describing the requested accommodation's effect on operations are: [DESCRIBE].

F. Retaliation (if applicable)

6.9. I engaged in protected activity under N.D.C.C. § 14-02.4-18 by [OPPOSING A DISCRIMINATORY PRACTICE / FILING A GOOD-FAITH COMPLAINT / TESTIFYING, ASSISTING, OR PARTICIPATING IN A COVERED MATTER] on [__/__/____]. Respondent later [DESCRIBE THE THREAT, RETALIATION, OR DISCRIMINATION, WITH DATES AND DECISIONMAKERS].

G. Harm Suffered

6.10. As a result of Respondent's conduct, I suffered the following employment and economic effects: [LOST WAGES, BENEFITS, POSITION, HOURS, OR OTHER EFFECTS; GIVE AMOUNTS AND DATES IF KNOWN]. I also experienced: [OTHER HARM, IF RELEVANT TO A REMEDY AVAILABLE UNDER AN APPLICABLE LAW].

H. Internal Complaint / Notice to Employer (if applicable)

6.11. I reported the discrimination internally on [__/__/____] to [NAME / TITLE — e.g., HR Director]. Respondent's response was [DESCRIBE — no investigation; perfunctory investigation; further retaliation].

I ask the Department to determine which alleged acts fall within the North Dakota Human Rights Act and to coordinate any separately covered federal employment claim through the applicable dual-filing process.

7. WITNESSES AND COMPARATORS

8. DOCUMENTS SUBMITTED

I submit (or will produce upon request) the following:

• ☐ Offer letter / employment contract
• ☐ Job description and performance evaluations
• ☐ Disciplinary records / write-ups
• ☐ Termination letter / separation paperwork
• ☐ Internal complaint and HR response
• ☐ Accommodation request and medical documentation
• ☐ Pay records / W-2s / paystubs
• ☐ Emails, text messages, voicemails reflecting discriminatory conduct
• ☐ Witness statements / declarations
• ☐ Employer policies / handbook / EEO policy
• ☐ Other: [__________]

9. REQUESTED RESOLUTION

Describe what would resolve the employment dispute: [REINSTATEMENT / HIRING / ACCOMMODATION / POLICY CHANGE / RESTORED WAGES OR BENEFITS / OTHER SPECIFIC RELIEF].

Amount and calculation of claimed back pay, if any: [________________________________].

N.D.C.C. § 14-02.4-20 authorizes injunctions, equitable relief, and back pay limited as stated in the statute. Neither the Department nor an administrative hearing officer may award compensatory or punitive damages under the NDHRA. Do not promise or request a remedy as available merely because another federal or state law may provide it in a different forum.

10. OTHER PROCEEDINGS AND FILING REVIEW

10.1. N.D.C.C. § 14-02.4-19 supplies distinct routes and deadlines. A direct employment action generally has a 300-day period. If a Department complaint was filed first, subsection 3 generally measures 90 days from dismissal or a written probable-cause determination. Subsection 5 separately governs a claimant with an applicable collective-bargaining, employment-contract, or public-employee recourse process. Filing a civil action requires dismissal of a pending Department action based on the same discriminatory acts.

10.2. The EEOC states that a charge filed with a FEPA is automatically dual-filed if federal law applies, and that the FEPA usually retains a charge initially filed with it for processing. Confirm the Department and EEOC charge numbers, filing dates, covered bases, respondent employee count, and which agency is processing the matter. Federal deadlines and pre-suit steps are claim-specific.

11. AFFIDAVIT AND SIGNATURE

By signing, I certify that the information provided is true and complete to the best of my knowledge and belief. I adopt this document and its attachments as my statement. I declare under penalty of perjury that the foregoing is true and correct.

Date: [__/__/____]

Charging Party Signature: [________________________________]

Print Name: [CHARGING PARTY NAME]

The current official SFN 14543 requires a signature to process a charge and contains a penalty-of-perjury declaration; it does not contain a notary block.

12. PRACTICE NOTES — NORTH DAKOTA DLHR PROCEDURE

• Use the current official intake. The Department currently accepts employment-discrimination intake through its online form or a printed and mailed signed SFN 14543. The official form also lists [email protected] as a return address. Confirm the live form and submission method on the filing date.
• Employment deadline. The Department says an employment charge must be filed no later than 300 days from the last date of harm. N.D.C.C. § 14-02.4-19(2) also sets a 300-day period for the covered administrative-complaint or direct-action route. Federal time limits depend on the claim and coverage facts; calculate them independently.
• Required form and signature. Section 14-02.4-23 requires a written complaint in the form prescribed by the Department. Current SFN 14543 says the complaint and accompanying statements must be signed to process a charge.
• What happens next. The current Department employment page says the Department will contact the submitter within 30 days. If jurisdiction exists, an investigator may conduct additional interviews and request supporting documents. The Department emphasizes conciliation; otherwise it determines probable cause and, after an unresolved probable-cause finding, provides an administrative hearing. N.D.C.C. §§ 14-02.4-22 and -23 govern the statutory process.
• Relief. Under § 14-02.4-20, administrative or judicial NDHRA relief may include injunctions, equitable relief, and limited back pay. The Department and its hearing officer may not award compensatory or punitive damages under the NDHRA.
• Court-route consequences. If a Department complaint was filed first, § 14-02.4-19(3) generally measures 90 days from dismissal or a written probable-cause determination for a district-court action. A pending Department action based on the same acts must be dismissed if the claimant elects court. Subsection 5 contains additional rules for certain contractual, collective-bargaining, and public-employee processes.
• Dual filing. EEOC identifies the North Dakota Department as a FEPA within the Minneapolis Area Office territory. EEOC says a FEPA-filed charge is automatically dual-filed when federal law applies, but coverage, employer-size thresholds, timeliness, and later notice requirements remain claim-specific. Preserve proof of both agencies' receipt.
• Records and conciliation. Under § 14-02.4-21, the filed complaint itself is an open record. Investigative information is exempt only during the periods stated in the statute, subject to authorized disclosures. Conciliation statements and actions have separate disclosure and evidentiary restrictions; a conciliation agreement is open unless the parties agree otherwise and the Department makes the statutory determination.
• Different complaint types. Do not use this employment packet for housing, public accommodations, public services, credit, general whistleblower, wage-hour, or federal-sector EEO complaints. The Department and EEOC publish separate intake routes, and the deadlines are not interchangeable.

13. SOURCES AND REFERENCES

• N.D.C.C. Ch. 14-02.4 (Human Rights) — https://ndlegis.gov/cencode/t14c02-4.pdf
• North Dakota Department of Labor and Human Rights — https://www.nd.gov/labor
• Current official SFN 14543 (11-2021) — https://www.nd.gov/eforms/Doc/sfn14543.pdf
• ND DLHR Submit a Charge of Discrimination — https://www.nd.gov/labor/submit-charge-discrimination
• ND DLHR Employment Discrimination — https://www.nd.gov/labor/human-rights/employment-discrimination
• ND DLHR FAQ — https://www.nd.gov/labor/discrimination-faq
• EEOC — Filing a Charge of Discrimination — https://www.eeoc.gov/filing-charge-discrimination
• EEOC — FEPAs and Dual Filing — https://www.eeoc.gov/fair-employment-practices-agencies-fepas-and-dual-filing
• EEOC Minneapolis Area Office — North Dakota FEPA listing — https://www.eeoc.gov/field-office/minneapolis/fepa
• EEOC Minneapolis Area Office — jurisdictional area — https://www.eeoc.gov/field-office/minneapolis/area

Disclaimer: This drafting companion is provided for informational purposes only and does not constitute legal advice or replace current official SFN 14543. An attorney licensed in North Dakota must review and customize the submission. Verify the current form, contact information, filing route, deadlines, and dual-filing status before filing.