Massachusetts > Statewide > Commission Against Discrimination
EEOC Intake Questionnaire - Massachusetts
| EEOC Intake Questionnaire Form. This is a Massachusetts form and can be used in Commission Against Discrimination Statewide . |
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U.S. EQUAL EMPLOYMENT OPPORTUNITY COMMISSION Thank you for contacting us. The information you gave us indicates that your situation may be covered by the laws we enforce. If you want to file a charge, you can start the process by filling out the questionnaire right away and mailing it back to us. Please send it to the EEOC office address given to you by the EEOC staff person you spoke to or the address provided to you online. If you would like to bring the questionnaire to us in person instead of mailing it to us, please call the number listed below to make sure the office will be open. You should be aware that filing a charge can take up to two hours. Please be sure to: · Answer all questions as completely as possible. · Include the location where you work(ed) or applied. · Complete all pages. · Attach additional pages if you need more space to complete your responses. · Contact a field office if you have questions about this form or if you would like to visit the office to finish filing a charge. You can find out more information about the laws we enforce and our charge-filing procedures on our web site at www.eeoc.gov. If you want to file a charge about job discrimination, there are time limits to file the charge. In many states that limit is 300 days from the date you knew about the harm or negative job action, but in other states it is 180 days. To protect your rights, it is important that you fill out the questionnaire and send it to us right away. Filling out and sending us this questionnaire does not mean that you have filed a charge. This questionnaire will help us look at your situation and figure out if we can help you. After you send us this questionnaire, someone from the EEOC should be contacting you by mail or by phone within 30 days to talk to you. If you don't hear from us in 30 days, please call us back at 1-866-408-8075. Sincerely, U.S. Equal Employment Opportunity Commission Phone: 1-800-669-4000 TTY: 1-800-669-6820 Internet: www.eeoc.gov Email: info@eeoc.gov American LegalNet, Inc. www.FormsWorkflow.com EQUAL EMPLOYMENT OPPORTUNITY COMMISSION INTAKE QUESTIONNAIRE Please immediately complete the entire form and return it to the U.S. Equal Employment Opportunity Commission ("EEOC"). REMEMBER, a charge of employment discrimination must be filed within the time limits imposed by law, generally within 180 days or in some places 300 days of the alleged discrimination. Upon receipt, this form will be reviewed to determine EEOC coverage. Answer all questions as completely as possible, and attach additional pages if needed to complete your response(s). If you do not know the answer to a question, answer by stating "not known." If a question is not applicable, write "n/a." Please Print. 1. Personal Information First Name: MI: Apt Or Unit #: County: ) Email Address: Sex: Male Female: Do You Have a Disability? Yes Yes No Asian White No Work: ( State: ) ZIP: Last Name: Street or Mailing Address: City: Phone Numbers: Home: ( Cell: ( Date of Birth: ) Please answer each of the next three questions. i. Are you Hispanic or Latino? ii. What is your Race? Please choose all that apply. Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native iii. What is your National Origin? Provide The Name Of A Person We Can Contact If We Are Unable To Reach You: Name: Address: Home Phone: ( ) City: Other Phone: ( ) Relationship: State: Zip Code: I believe that I was discriminated against by the following organization(s): (Check those that apply) Employer Union Employment Agency Other (Please Specify) 2. Organization Contact Information County: State: Zip: Phone: ( ) Organization #1 Name: Address: City: Type of Business: Human Resources Director or Owner Name: Job Location if different from Org. Address: Phone: Number of Employees in the Organization at All Locations: Please Check () One Less Than 15 Organization #2 Name: Address: City: State: Zip: County: Phone: ( ) 15 - 100 101 - 200 201 - 500 More 500 American LegalNet, Inc. www.FormsWorkflow.com 2 Type of Business: Human Resources Director or Owner Name: Job Location if different from Org. Address: Phone: Number of Employees in the Organization at All Locations: Please Check () One Less Than 15 15 - 100 101 - 200 201 - 500 More 500 3. Your Employment Data (Complete as many items as you can) Date Hired: Pay Rate When Hired: Job Title at Time of Alleged Discrimination: Name and Title of Immediate Supervisor: If Applicant, Date You Applied for Job Job Title Applied For Job Title At Hire: Last or Current Pay Rate: 4. What is the reason (basis) for your claim of employment discrimination? FOR EXAMPLE, if you are over the age of 40 and feel you were treated worse than younger employees or you have other evidence of discrimination, you should check () AGE. If you feel that you were treated worse than those not of your race or you have other evidence of discrimination, you should check () RACE. If you feel the adverse treatment was due to multiple reasons, such as your sex, religion and national origin, you should check all three. If you complained about discrimination, participated in someone else's complaint or if you filed a charge of discrimination and a negative action was threatened or taken, you should check () RETALIATION. Race Sex Age Disability National Origin Color Religion Retaliation Pregnancy Other reason (basis) for discrimination (Explain). 5. What happened to you that you believe was discriminatory? Include the date(s) of harm, action(s) and include the name(s) and title(s) of the persons who you believe discriminated against you. (Example: 10/02/06 Written Warning from Supervisor, Mr. John Soto) A) Date: Action: Name and Title of Person(s) Responsible: B) Date: Action: Name and Title of Person(s) Responsible: Describe any other actions you believe were discriminatory. (Attach additional pages if needed to complete your response.) American LegalNet, Inc. www.FormsWorkflow.com 3 6. What reason(s) were given to you for the acts you consider discriminatory? By whom? Title? 7. Name and describe others who were in the same situation as you. Explain any similar or different treatment. Who was treated worse, who was treated better, and who was treated the same? Provide race, sex, age, national origin, religion, and/or disability status of comparator if known and if connected with your claim of discrimination. Add additional sheets if needed. Full Name 1. 2. 3. Job Title Description Answer
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