EEO Discrimination Complaint Intake
First Name
Last Name
Email
Phone
Employer / Agency
Job Title
Work Location
Incident Start Date
Incident End Date (if ongoing, leave blank)
Basis of Discrimination (select all that apply)
Race
Color
Religion
Sex (including pregnancy, sexual orientation, gender identity)
National Origin
Age
Disability
Genetic Information
Retaliation
Other
Hold Ctrl (Windows) or Command (Mac) to select multiple.
Type of Issue
Select one
Hiring
Termination
Promotion / Pay
Harassment / Hostile Work Environment
Reasonable Accommodation
Retaliation
Other
Describe what happened
Witnesses (names and contact info)
Requested Remedy / Outcome
Supporting Documents (optional)
I certify that the information provided is accurate to the best of my knowledge.
Thank You
Your intake has been submitted successfully. Reference #:
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