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
If you have started a questionnaire and have saved it in a previous session, please provide a reference number
to retrieve your previous answers.
To begin, please click on the "PERSONAL" button at the top of the page.
What is your race? Please check all that apply.
In what country were you born?
What happened to you that you believe was discriminatory? Include:
• the date(s) of harm,
• the action(s),
• the name(s) and title(s) of the person(s) who you believe discriminated against you.
(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, ie., 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 page.
Please check all that apply:
What is the disability (or disabilities) that you believe is the reason for the adverse action taken
Does the condition(s) prevent or limit you from doing anything? If so, please describe.
Did you ask for changes, modifications or assistance (accommodations) because of your disability?
Describe the changes or assistance you requested, and include the dates of those
What was the response to your request(s)?