Your name (required)
Your email (required)
Phone Number
Address
City
State
Zip
Name of employer (for conflict check)
Name of responsible official(s) or supervisor(s)
Location (city and state) Where you work
Number of employees at your location
Total number of employees in the company
Your position title
Years in your current position
Years at your employer
Indicate the basis of your legal claim RaceAgeSexRetaliationReligionDisabilityPregnancyFamily/Medical LeaveFamily ResponsibilityBreach of ContractWrongful TerminationWhistleblowingOther
If other, please specify
Your race
Your age
Your religion
Briefly describe the bad thing(s) that happened, or the harm you suffered (such as fired, demoted, suspended, not promoted, harassed, etc.)
Dates when the event(s) happened
Briefly describe what makes you think that the employer was motivated by discrimination, retaliation, or other illegal motive.
Do you have a contract or hire letter (if yes, please attach)? YesNo Add a file
Did you sign an arbitration agreement (if yes, please attach)? YesNo Add a file
Are there any policies or handbook provisions at issue? YesNo
If yes, please describe them
Are there any people who witnessed these events or whom you think can be helpful witnesses?
Have you filed a grievance or EEO complaint with your employer, your union or any governmental agency (such as EEOC or the Human Rights Commission)? If so, what is the status of that complaint?
What do you think would be a satisfactory result or resolution?
