Employment Intake Form

Please completely answer the following questions, telling us why you believe that you have been discriminated against in employment. 
 

Please use the TAB key to move through the fields.  Pressing enter will submit the form to the HRC.

Name

First Name Last Name Middle Initial
Address
City
State
Zip Code
Home Phone Number
Work Phone Number
Date of Birth (MM/DD/YEAR)
E-mail address
Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other (Specify)
Ethnicity

Hispanic or Latino

Not Hispanic or Latino

I was discriminated against by:  Employer    Union    Employment Agency

Company Name
Address
City
State
Zip Code
Telephone Number
Date of Hire (MM/DD/YEAR)
Rate of Pay per Hour
Hours per Week
Position Title
Name of: (Please give names of as many as possible)
Owner:
Manager/Supervisor:
Personnel Director:
Number of employees at Company: (Please check appropriate box)
Under 8 8 - 14 15 - 100
101 - 200 201 - 500 501 +
Are you still employed by this company?  Yes     No
If not, please list when your employment ceased
Did you leave your employment voluntarily, or were you terminated?

Have you ever filed a complaint like this before?  Yes  No; If YES, please list where you filed the complaint, when the complaint was filed and against whom the complaint was filed:

Does your employer have an internal complaint procedure? Yes    No

If Yes, please answer the following:

Have you taken advantage of this procedure to make your present concerns known to a higher level management? Yes    No

If you have filed such a complaint, please record the date(s) of your filing(s) and results of said filing(s), if any.

If you did not file a complaint, please explain why you did not: 

Do you believe that the action taken against you was because of: (Check all that apply and specify, where applicable)

Race or Color

 National Origin
Black Hispanic
White Asian or Pacific Islander
Other (Specify) American Indian
Other (Specify)
Sex Disability
Male Physical
Female Mental
Age (40+) Pregnancy
Sexual Harassment Sexual Orientation/Gender Identity

What action was taken against you that you believe to be discriminatory? (i.e. not hired, disciplined, terminated, etc.)

   

Who took that action?   

Who do you believe received better treatment than you?

Please list the names, addresses and telephone numbers for any individuals whom you believe would be able to provide information about the situation that you are complaining:

Name
Address
City/State/Zip
Telephone Number
Name
Address
City/State/Zip
Telephone Number
Name
Address
City/State/Zip
Telephone Number
Name
Address
City/State/Zip
Telephone Number

Please provide the name of an individual in the local area, who does NOT live with you, who would know how to reach you at any time.  This person must have a telephone number and a street address.

Name
Relationship
Address
City/State/Zip
Telephone Number

By submitting this information, you affirm that the information contained in your response to this Intake Form is true and correct to the best of your knowledge and belief.

Send mail to webmaster with questions or comments about this web site.
Last modified: 04 Jun 2023