Civil Rights Center
Complaint Information Form
1. Complainant Information:
State your name and address:Your telephone number(s):
Home Number: ( ) -
Work Number: ( ) -
2. Respondent Information:
Provide name and address of agency involved:
Telephone Number: ( ) -
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?
Date of final decision (if any)
b. Have 90 days elapsed since you filed or attempted to file this complaint at the local level?
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)
_____Welfare to Work
8. Basis of Complaint: Which of the following best describes why you believe you were discriminated against: (Check)
_____National Origin: Specify
_____Sex: Specify [ ] Male [ ] Female
_____Age: Specify Date of Birth:
_____Political Affiliation: Specify
9. Do you think the discrimination against you involved: (Check one)
_____Your job or seeking employment?
_____Your using facilities or someone providing/not providing you with services or benefits?
If so, which of the following are involved?
_____ Hiring _____Harassment
_____Wages _____Union Representation
_____Job Classification _____Union Activity
_____Grievance Procedure _____Benefits
_____Layoff/Furlough _____Performance Appraisal
_____Recall (From Layoff-Furlough) _____Discipline/Reprimand
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?
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:
Case or Docket Number
Date of Trial or Hearing:
Location of agency or court
Name of Investigator:
Status of Case:
17. Sign (Complaint NOT VALID unless signed)
For DOL use only
CIF Received by CRC: _____Accepted_____ Not Accepted
Case Number: ________
OMB Control Number 1225-0077 Exp. Date 5/31/2011
DL 1-2014a (Rev’6/87)