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How to Enforce Employment Rights Under the Americans with ...

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Sample EEOC Intake QuestionnaireTitle I - Charge of Discrimination - EEOC FormALLEGATIONS OF EMPLOYMENT DISCRIMINATIONPlease immediately complete <strong>the</strong> entire form and return it <strong>to</strong> <strong>the</strong> U. S. Equal <strong>Employment</strong> OpportunityCommission (“EEOC”). Answer all questions as completely as possible, and attach additional pages if needed<strong>to</strong> complete your response(s). Incomplete responses will delay fur<strong>the</strong>r processing of your charge by EEOC. Ifyou do not know <strong>the</strong> answer <strong>to</strong> a question, answer by stating “not known.” If a question is not applicable, write“n/a.” REMEMBER, a charge of employment discrimination must be filed <strong>with</strong>in <strong>the</strong> time limits imposed bylaw, generally <strong>with</strong>in 300 days of <strong>the</strong> alleged discrimination.PERSONAL BACKGROUND INFORMATION:Name: Mr./Ms. _______________________________________________________________________Address: ____________________________________________________________________________Phone Number: (day)( ) ____________________ (night) ( ) ______________________Date of Birth: ________________ Soc. Sec. # ____________________ Race __________________RESPONDENT INFORMATION (Employer, union, employment agency against whom <strong>the</strong> charge is beingfiled)Respondent Name ___________________________________________________________________Address (If employer, location where you actually worked or sought employment - If you worked out of yourhome, state that, and give <strong>the</strong> full address of <strong>the</strong> company home office or headquarters; if union oremployment agency, give address where you conducted business.)____________________________________________________________________________________________________________________________________________________________________City/State/Zip Code____________________ /County ____________________Approximate <strong>to</strong>tal number of employees ______________________________________________________Type of business ________________________________________________________________________DATE OF HARM (last date any harm which you consider discrimina<strong>to</strong>ry happened):TYPE OF HARM (<strong>the</strong> kind of discrimination that happened <strong>to</strong> you, for example, discharge, denial of hire,harassment):__________________________________________________________________________________27

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