Home Page - IHRCQ

PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY.

If you are a Federal employee and wish to file a complaint against your Federal employer, please disregard this questionnaire and contact your Federal department's EEO office.

Please complete the questions shown on the following pages. A charge of discrimination must be filed within the time limits imposed by law, generally within 300-365 days of the alleged act of discrimination. This questionnaire will be reviewed to determine if the act is covered by IHRC. ANSWER ALL QUESTIONS that pertain to your situation, as completely as possible. If you do not know the answer to a question, answer by stating "not known." If a question is not applicable to your situation, write "NA".

This intake questionnaire is not a complaint, and you will not have filed a complaint of discrimination by completing this form. The IHRC will review this questionnaire and, if necessary, follow up with you. When the information is complete, a charge of discrimination will be sent to me for my signature. The charge will not be filed and served until the IHRC receives the forms with my signature, at which time an investigator will be assigned to my case. A copy of the charge of discrimination you sign will be sent to the employer, employment agency, union, or organization and will be the basis for the IHRC investigation.

To begin, please click on the "Next" button below.

PLEASE REVIEW AND SUBMIT YOUR QUESTIONNARIE

Personal Information

First Name

Middle Initial

Last Name

Mailing Address

City

State

Zip Code

Primary Phone No.

Secondary Phone No.

Fax Number

Sex

Date of Birth

What is your race? Please check all that apply.

Are you Hispanic of Latino? Check if yes.

Native American/Alaska Native

Native Hawaiian/Pacific Islander

Black/African American

White

Asian

In what country were you born?

Please provide the name of a contact person who does not live with you.

First Name

Last Name

Mailing Address

City

State

Zip Code

Primary Phone No.

Secondary Phone No.

Relationship

Please provide the following information for your claim.

I believe I was discriminated against in:

What is the basis(es) for your claim of discrimination? Please check all that apply.

Race

National Origin (ethnicity or ancestry)

Color (different skin share in same race)

Sex (Please select all that apply)

Female

Male

Pregnancy

Sexual Orientation

Gender Identity

Religion

Age (40+)

Disability

Retaliation (If checked, you MUST identify one or more of the following underlying bases.)

Race

National Origin (ethnicity or ancestry)

Color (different skin share in same race)

Sex

Religion

Age (40+)

Disability

Yes - Have you previously filed a charge in this matter with IHRC, EEOC, or another agency?

Agency Name

Filed Date

Organization Name

Street Address

City

State

Zip Code

County

Phone

Type of Business

Corporate Location

No. of Employees

Date Hired

Job Title at Hire

Job Title at Time of Discrimination

Hire Pay Rate

Last Pay Rate

Discharge Date

Supervisor Name

Supervisor Title

What happened to you that you believe was discriminatory? Include:

(Example: 10/02/13 - Discharged by Mr. John Doe, production supervisor.) Add as many incidents as necessary

Why do you believe these actions were discriminatory, i.e., because of your race, color, national origin, sex, religion, age, disability, or retaliation?

Name or otherwise identify others who were in the same situation as you. Explain any similar or different treatment. Highlight who was treated better, who was treated worse, and who was treated the same as you.

Are there any witnesses to the alleged discriminatory incidents? If yes, please identify them and tell us what you believe they will say.

Did you report the discrimination to anyone, i.e. supervisor, manager, human resources, or owner?

Answer the following questions ONLY if you are claiming discrimination based on disability. If not, you may skip this section.

Please check all that apply:

Actual or Current Disability

History of Record of Disability

Regarded as Disabled

Accomodation:

Did you ask for changes, modifications or assistance (accommodations) because of your disability?

Date of Initial Request

I asked verbally

I asked in writing

What is the disability (or disabilities) that you believe is the reason for the adverse action taken against you?

Does the condition(s) prevent or limit you from doing anything? If so, please describe.

Describe the changes or assistance you requested, and include the dates of those requests.

What was the response to your request(s)?