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?

_____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


CIF Received by CRC: _____Accepted_____ Not Accepted		Case Number: ________
By: _____________________________________		Date:______________
OMB Control Number 1225-0077 Exp. Date 5/31/2011		DL 1-2014a (Rev’6/87)

NOTICE ABOUT INVESTIGATORY USES OF PERSONAL INFORMATION