Civil Rights Center
Complaint Information
Form
1. Complainant Information:
State your name and address: Your telephone number(s):
Home Number: ( )
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Work Number: ( )
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2. Respondent Information:
Provide name and address of agency involved:
Telephone Number: ( )
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3. What is the most convenient time and place for us to contact you
about this complaint?
4. To your best recollection on what date(s) did the discrimination
take place?
Date of first occurrence:
Date of most recent occurrence:
5. Have you ever attempted to resolve this complaint at the local
Level? _____No or _____Yes
a. Have you been provided with a final decision at the local level
regarding your complaint?
_____No
_____Yes
Date of final decision (if any)
b. Have 90 days elapsed since you filed or attempted to file this
complaint at the local level?
_____No
_____Yes
Date you filed or attempted to file your complaint at the local
level.
6. Explain as briefly and clearly as possible what happened and how
you were discriminated against. Indicate who was involved. Be sure to
include how other persons were treated differently from
you. Also attach any written material pertaining to your case.
7. To the best of your knowledge, which of the following Department
of Labor programs were involved? (Check one)
_____Workforce Investment Act (WIA) _____Job Training (JTPA)
_____MSHA _____Welfare to Work _____OSHA _____Job Service
_____WIN _____Youth _____Unemployment Insurance _____Job
Corps _____Apprenticeship _____Older Americans _____New Directions
_____Displaced Worker _____Other: Specify
8. Basis of Complaint: Which of the following best describes
why you believe you were discriminated against: (Check)
_____Race: Specify _____Color: Specify _____Religion:
Specify _____National Origin: Specify _____Sex: Specify [ ] Male
[ ] Female _____Age: Specify Date of Birth: _____Disability:
Specify _____Political Affiliation: Specify _____Citizenship:
Specify _____Reprisal/Retaliation: Specify _____Other: Specify
9. Do you think the discrimination against you involved: (Check
one)
_____Your job or seeking employment?
or
_____Your using facilities or someone providing/not providing you with
services or benefits?
If so, which of the following are involved?
_____ Hiring
_____Harassment
_____Transition
_____Access/Accommodation
_____Wages
_____Union
Representation _____Job
Classification
_____Union
Activity
_____Discharge/Termination
_____Application
_____Promotion
_____Enrollment _____Training
_____Referral _____Transfer
_____Exclusion
_____Qualification/Testing
_____Placement
_____Grievance
Procedure
_____Benefits
_____Layoff/Furlough
_____Performance
Appraisal _____Recall (From Layoff-Furlough)
_____Discipline/Reprimand _____Seniority
_____Intimidation/Reprisal _____Other:
Specify
10. Why do you believe these events occurred?
11. What other Information do you think is relevant to our
investigation?
12. If this complaint is resolved to your satisfaction, what
remedies do you seek?
13. Please list below any persons (witnesses, fellow employees,
supervisors, or others) that we may contact for
additional information to support or
clarify your complaint:
Name
Address
Telephone Number
14. Do you have an attorney?
_____Yes
_____No
If yes, please provide name, address and phone:
Attorney
Name
Address
Telephone Number
15. Have you filed a case or complaint with any of the
following?
____ Civil Rights Division, U S Dept of Justice ____ U S Equal
Employment Opportunity Commission ____ Federal or State court ____ Your
State or local Human Relations/Rights Commission
16. For each item checked in #15 above, please provide the following
Information:
Agency: Data Filed: Case or Docket Number Date of Trial or
Hearing: Location of agency or court Name of Investigator: Status of
Case: Comments:
17. Sign (Complaint NOT VALID unless signed)
_______________________________________
___________________
Name:
Date:
For DOL use only
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CIF Received by CRC: _____Accepted_____ Not
Accepted |
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Case Number: ________ |
By: _____________________________________
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Date:______________
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OMB Control Number 1225-0077 Exp. Date
5/31/2011 |
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DL
1-2014a
(Rev’6/87) |
NOTICE ABOUT INVESTIGATORY USES OF PERSONAL
INFORMATION
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