California > Statewide > Dept Of Fair Employment-Housing > Employment Discrimination
Pre-Complaint Questionnaire-Employment DFEH-600-03 - California
| Pre-Complaint Questionnaire-Employment Form. This is a California form and can be used in Employment Discrimination Dept Of Fair Employment-Housing Statewide . |
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STATE OF CALIFORNIA STATE AND CONSUMER SERVICES AGENCY DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING Interview Date: Approval: Interviewer: FOR OFFICIAL USE ONLY Processing Time: :MIN Action Taken: Computer Entry: :HR PRE-COMPLAINT QUESTIONNAIRE - EMPLOYMENT The information requested on this form will assist the Department in helping you. There is no guarantee that the information submitted will result in an investigation. Please check or answer only those questions that apply. PLEASE PRINT NAME ADDRESS Street First DATE ______________ Middle ___________ Last County ZIP Code ____________ Apt. Number City TELEPHONE NUMBER: WORK ( ) Days: HOME ( ) Time: Area Code Area Code I prefer to be contacted by telephone at work/home: Person to contact if you cannot be reached or if you move: Name TELEPHONE ( ) Area Code ___________ I WISH TO COMPLAIN AGAINST: (Name and address of company, government entity [city, county, state], employment agency, union, etc.) NAME ______________ ADDRESS _______________ Street City County ZIP Code TELEPHONE NUMBER: WORK ( ) Area Code NUMBER OF EMPLOYEES (Estimate, if necessary) Job Site ______ Company-Wide ______ I WISH TO COMPLAIN AGAINST: NAME ______________ TITLE ADDRESS ____________ (if known) (Other named individuals who were involved in this particular complaint.) _________ Street TELEPHONE ( City Area Code ) __ County ZIP Code EMPLOYER LISTED ON W-2 FORM: NAME ______________ ADDRESS _____________ (if known) Street City (CONTINUE ON BACK IF NECESSARY) County ZIP Code 1. I believe I was discriminated against because of my (please circle): Race Color Sex Sexual Orientation Cancer Genetic Characterisitcs Pregnancy Marital Status Age (40 and over) Denial of Family Care Leave National Origin/Ancestry (Please specify) Religion ___________________ ____________________________ (Please specify) Disability (including AIDS) ________________ (Please specify) 2. Circle the discriminatory treatment and indicate the date occurred: Terminated/Laid Off _____________ Not Hired _____________ Denied Promotion _________________ Denied Accommodation _____________ Harassed ____________________ Denied Equal Pay _____________ Denied Leave (Pregnancy/Family Care Leave) ________________ Denied Accommodation for Pregnancy ______________________ Retaliation ____________________ Impermissible Non-Job-Related Inquiry _________________________________ Other ____________________________________________________________________________________ DFEH-600-03I (06/03) American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com 3. Why do you believe the unfair treatment was discrimination? (If others were treated better than you, give names, addresses and examples.) 4. List the names, addresses, job titles and telephone numbers (if possible) of witnesses, co-workers, or others you feel could provide evidence. Explain what you think each witness will be able to tell us. Name and Address Title/Relationship Telephone Numbers Home Work Can provide information regarding: Name and Address Home Work Title/Relationship Telephone Numbers Can provide information regarding: (Use extra sheets of paper for additional witnesses, if necessary.) 5. EMPLOYMENT DATA: (Complete as many items as you can.) A. B. C. D. E. Date hired or applied for job: Job title/salary at time of discrimination: Name and title of immediate supervisor or interviewer: If you? your employment was terminated, who replaced: If your employment was terminated or if you were refused a job, have you since been employed? Date of hire: Salary: Job Title: F. If not hired: < How did you know about the job and/or salary? < Did you apply by written application or verbally? < To whom did you submit the application? < How did you find out you had been refused? < Who got the job, salary, etc. (if known)? Yes No Date Date 6. Have you filed a complaint with the U.S. Equal Employment Opportunity Commission (EEOC) before coming to DFEH? Yes ______ No ______ Date _______________________ 7. Have you talked to an attorney concerning this problem? Yes ______ No ______ NAME ADDRESS TELEPHONE ( ) Area Code 8. PERSONAL DATA: PRIMARY LANGUAGE RACE/ETHNICITY (Check box that best describes) Native American Asian/Pacific Islander (specify) ________________ Hispanic (specify) DATE OF BIRTH ___ ___ / ___ ___ / ___ ___ SEX: __________________ African-American African Other Caucasian (non-Hispanic) ____________________________ SOCIAL SECURITY NUMBER: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ (The Federal Privacy Act of 1974 prohibits a state government agency from requiring disclosure of an individual's Social Security Number. Disclosure of your Social Security Number is voluntary.) Male Female DFEH-600-03I (06/03) American LegalNet, Inc. www.FormsWorkflow.com DO NOT WRITE IN THIS AREA INTERVIEWER'S NOTES Complainant's assertions: What does Complainant say the employer's position will be? Comparative data/relevant information: What does Complainant want as a remedy? Complaint taken for investigation: Yes ___ No ___ If taken for filing purposes only, explain why: If NO, was "b" offered? Yes ___ No ___ If not taken, rationale: Complainant advised of Pilot Mediation Program? Yes ___ No ___ Complainant advised of statute of limitations? Yes ___ No ___ Complainant advised of other agencies? Yes ___ No ___ FOR OFFICIAL USE ONLY BASIS ___ ___ ACT ___ ___ REJECT ___ Date statute runs: DFEH CODE: LAW ____ PUBLIC ___ DFEH-600-03I (06/03) American LegalNet, Inc. www.FormsWorkflow.com
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