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

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ADDITIONAL INFORMATIONALLEGATIONS OF DISCRIMINATION (p. 8)1. Choose one of the following:a) ( ) I want to file a charge.b) ( ) I DO NOT WANT to file a charge at this time.c) ( ) I want to speak with an EEOC Representative before this is filed as a charge.I can be contacted at (area code/telephone number) _____________________________.The best days and times to contact me are _____________________________________.2. Indicate which of the following applies:a) ( ) I have not filed a charge with any other agency concerning these same matters:b) ( ) I have filed a charge with the agency/agencies named below concerning these matters:Name of Agency__________________________________________________________Date Filed _______________________________________________________________Agency docket number_____________________________________________________c) ( ) I am scheduled for an interview with the agency named below:Name of Agency _____________________________________________________Date of Scheduled Interview ____________________________________________Location of Interview __________________________________________________Name of interviewer ____________________________________________________d) ( ) I have received a Questionnaire to be completed from the agency named below:Name of Agency_______________________________________________________e) ( ) I mailed the Questionnaire back to the agency named above on or about:___________________________Signature___________________________Date34
Sample Charge Form (ACRD/EEOC)Title I - Charge of DiscriminationCHARGE OF DISCRIMINATIONThis form is affected by the Privacy Act of 1974; see Privacy Act Statement onreverse before completing this form_____________________________________________________________ and EEOC(State or local Agency, if any)NAME (Indicate Mr., Ms., or Mrs.)ENTER A CHARGE NUMBER FEPA EEOCHOME TELEPHONE NO. (Include AreaCode)STREET ADDRESSCOUNTYCITY, STATE AND ZIP CODENAMED IS THE EMPLOYER, LABOR ORGANIZATION, EMPLOYMENT AGENCY, APPRENTICESHIP COMMITTEE,STATE OR LOCAL GOVERNMENT AGENCY WHO DISCRIMINATED AGAINST ME (If more than one list below.)NAME NO. OF EMPLOYEES/MEMBERS TELEPHONE NUMBER (Include AreaCode)STREET ADDRESSCITY, STATE AND ZIP CODENAMETELEPHONE NUMBER (Include AreaCode)STREET ADDRESSCITY, STATE AND ZIP CODECAUSE Of DISCRIMINATION BASED ON (Check appropriate box(es)) RACE COLOR SEX RELIGION NATIONAL ORIGIN AGE RETALIATION OTHER (Specify)DATE MOST RECENT ORCONTINUING DISCRIMINATIONTOOK PLACE(Month, day, year)THE PARTICULARS ARE (If additional space is needed, attach extra sheet(s)): I also want this charge filed with theI will advise the agencies if I change my address or telephonenumber and I will cooperate fully with them in the processingof my charge in accordance with their procedures.I declare under penalty of perjury that the foregoing is true andcorrect.DateCharging Party (Signature)NOTARY - (when necessary to meet State and Localrequirements)I swear or affirm that I have read the above charge and that itis true to the best of my knowledge, information and belief.SIGNATURE Of COMPLAINANTSUBSCRIBED AND SWORN TO BEFORE ME THISDATE(Day, month, and year)EEOC FORM 5PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE AND MUST NOT BE USEDMAR 8435
Page 1: How to Enforce Employment Rights Un
Page 4 and 5: Sample Charge Form (ACRD/EEOC) 35Sa
Page 6 and 7: There are limits to the types of la
Page 8 and 9: discrimination with the EEOC agains
Page 10 and 11: discrimination has been issued, the
Page 14 and 15: Example of a charge filed by a pers
Page 16: D. How To File A Charge Of Discrimi
Page 19 and 20: the type of discrimination (e.g., d
Page 21 and 22: For example, the investigator may a
Page 23 and 24: litigate, it will send the charging
Page 25 and 26: the employee to find an effective a
Page 27 and 28: early if the agency does not believ
Page 29 and 30: efore you sign, let the staff of th
Page 31 and 32: Sample EEOC Intake QuestionnaireTit
Page 33 and 34: ALLEGATIONS OF DISCRIMINATION (p. 3
Page 35 and 36: ALLEGATIONS OF DISCRIMINATION (p. 5
Page 37: ALLEGATIONS OF DISCRIMINATION (p. 7
Page 41 and 42: Sample Notice of Right to Sue Lette
Page 43 and 44: Section 706(f) (1) and (f) (3) of t
Page 45: Sample ChronologyChronologyRaul Cha

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