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  EMPLOYMENT COMPLAINT QUESTIONNAIRE
  Instructions for Complainants Return to –Compliance Section
 

(1) Try to answer every question in the sections which apply to your complaint and give complete and detailed responses.

(2) Think carefully before answering each question.

(3) When you're done, click the "Submit" Button at the bottom of the form.

(4) This is not a formal complaint form. The Human Rights Office will determine whether you have submitted enough information to file a formal complaint. The Human Rights Office will send you a completed formal complaint for signature and notarization if you have provided sufficient evidence.
Major Life Activities : Major life activities means functions such as caring for one's self performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.
Sections A, B, and C must be completed
(*) required fields

Section A
Complainant Information - Person(s) filing complaint
*First Name:
  
Middle Initial:
*Last Name:
  
*Birthdate:
  
Age:
 
*Home Address:
  
*City:
  
*State:
*Zip Code:
    
*Home Phone Number:
(123-345-6789)
    
E-Mail Address:
  
Fax Number:
Cell Phone/Pager:
  
 
Business Address:
City:
State:
Zip Code:
  
Business Phone Number:
(123-345-6789)
  
   

 

Complainant's Attorney Information
Attorney's Name:
Office Address:
City:
State:
Zip Code:
  
Office Telephone Number:
(123-345-6789)
  
What other agencies/organizations have you contacted for assistance??
 

 

Were you given a Case Number?
Yes (if yes, what is the case No.)
   

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Section B
Respondent - Union, employer, employment agency, labor organization, which committed act of discrimination
*Name of Respondent:
  
  (indicate if incorporated, limited partnership, etc.)
*Respondent's Address:
  
*City:
  
*State:
*Zip Code:
    
Telephone Number:
(123-345-6789)
  
 
If the actual place where the discrimination occurred is a different site than the Respondent's address listed above, provide the address where it happened: (NOTE: It MUST be located in Montgomery County, MD)
Address:
City:
State:
Zip Code:
  
Telephone Number:
(123-345-6789)
  
   
Corporate Name of Respondent (if known):
  (indicate if incorporated, limited partnership, etc.)
Corporate Address:
City:
State:
Zip Code:
  
Corporate Telephone Number:
(123-345-6789)
  
   

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Section C
General Information : How did discrimination occur?
What was the discriminatory basis for the Respondent's action(s)?
 
   

 

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Section D
Disability
Are you alleging discrimination based on disability?
 If No skip this section

Describe how your employer became aware of your disability.

When did your employer become aware of your disability?

With whom did you speak to about your disability?
Name:
  
Does the employer believe/perceive that you have a disability?

How does your disability limit your ability to perform "Major Life Activities" and the essential functions of your job?
What accommodation, if any, did you request from the employer and when did you request it?

How did the employer respond to your request for an accommodation of your disability? (i.e. did the employer refuse, tell you the accommodation was too costly, offer you an alternative (specify), tell you it would take more time, etc.)

How are you otherwise qualified (able to perform the essential functions of the job for the position)?

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Section E
Promotion/Transfer
Why do you believe your denial of promotion(s)/transfer(s) was discriminatory? Provide a detailed explanation showing the connection between the denial(s) and the bases for your claim.

 

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Section F
Hiring
Why do you believe that not being hired was discriminatory? Provide a detailed explanation showing the connection between not being hired and the bases of your claim.

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Section G
Discharge/Disciplinary Action
Why do you believe your discharge/disciplinary action(s) were discriminatory? Provide a detailed explanation showing the connection between your not being hired and the bases for your claim.

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Section H
Retaliation
Did you participate in an investigation of an EEO charge or did you complain about unlawful EEO practices in your workplace?
Participation Opposition
Why do you believe the employer's action(s) are retaliatory? Provide a detailed explanation showing the connection between the employer's action(s) and bases for your claim.

 

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Section I
Wages/Benefits
Why do you believe the differences in wages/benefits are discriminatory? Provide a detailed explanation showing the connection between the employer's action(s) and bases for your claim.

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Section J
Pregnancy-related
Why do you believe the employer's action(s) are discriminatory? Provide a detailed explanation showing the connection between the employer's action(s) and bases for your claim.

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Section K
Harassment
Describe any behavior, methods, or conditions which you believe created an offensive, harassing environment for you.
Describe all the comments and behavior you felt were offensive while you were at work and identify the source(s) of the the comments and behavior. Be specific.

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Section L
Unions
What is the complete name of the union which you allege failed to represent you?