Intake Questionnaire

EEOC Complaint Form Instructions

Provide the following information in the EEOC Complaint Form:

1. Add your personal details - full name, mailing address, telephone numbers, date of birth, sex, race, and national origin. Check the box if you have a disability. Identify the individual to contact if the EEOC cannot reach you;
2. Enter the details of the organization that discriminated against you and indicate your employment data;
3. Describe the basis for your employment discrimination claim. Explain what and when happened to you that you believe was discriminatory and why you consider those actions discriminatory;
4. Record the names of employees who were treated better, worse, or the same as you;
5. If you claim discrimination based on disability, state what exactly led to the adverse action against you, indicate the medications and medical equipment you use, and explain whether you have asked the employer to assist you to perform the job because of the disability;
6. Name the individuals who might have witnessed the discrimination. If you previously filed any discrimination complaints, identify the agencies and dates of filing;
7. Authorize the EEOC to file a discrimination charge if you wish. Sign and date the form.