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Human Relations - Employment Discrimination
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HUMAN RELATIONS DEPARTMENT
CIVIL RIGHTS DIVISION
Employment Discrimination Complaint Intake Form

Instructions:
Please fill out this complaint form to the best of your ability. The Department will need specific information to determine if your claim can be processed as a charge and to investigate the charge if it is accepted. Your entry will be posted as of 08/20/2014. If you have any questions while filling out this form, please call the Kansas City Department of Human Relations at (816) 513-1836.

1. PERSONAL INFORMATION
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Social Security #:
Home Phone:
Work Phone:
Pager/Mobile:

CONTACT INFORMATION: (Someone who does NOT reside with you and will know how to contact you.)
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Phone:
Please note: If any of the above information should change please notify the Human Relations Department immediately. Failure to do so could mean that your case may be closed.

2. FILING INFORMATION
Have you filed this complaint with any other agency?
Yes
No
If so, which one and on what date?

3. RESPONDENT INFORMATION: (The Respondent is the person, agency, company, etc., that you are complaining against.)
Respondent Name:
Street Address:
City:
State:
Zip:
Phone Number:
No. of Employees:
Name and Title of Chief Executive:

4. EMPLOYMENT INFORMATION
Date Hired:
Most Recent Job Title:
Salary:
Supervisor's Name & Title:

5. BASIS OF DISCRIMINATION
You believe that the action(s) taken against you was(were) because of your:
Age (over 40) Race/Color Sex
Disability Religion Sexual Orientation
National Origin or Ancestry Retaliation Gender Identity

6. COMPLAINANT STATEMENT
What did the respondent do? List each action that you believe was discriminatory. For example: I was terminated, not hired, not promoted, disciplined more harshly, retaliated against, etc. Be specific regarding who, what, when and where. Then state why you believe that the treatment you received was because of the basis that you checked above.

Add all pertinent information. If you have relevant documents that are saved as files on your computer, please attach(upload) them at the end of this form. Please mail in any other documents that are not able to be uploaded and reference those documents in the following entry field.

If applicable, provide the names and job titles of persons who you believe were treated more favorably than you because you belong to the category checked above. Include the category (race, gender, age, etc.) of the person (s) you are comparing yourself to.

Name and Address:
Category:

Name and Address:
Category:

Name and Address:
Category:

7. HARASSMENT (SEXUAL OR RACIAL)
If your complaint involves sexual harassment or racial harassment, please state whether or not you reported it to management, who in management you reported to, and what was the response.

8. RESPONDENT RESPONSE
What reasons were given by your employer for the actions taken against you?

9. WITNESS INFORMATION
If known, please provide the names, home addresses and telephone numbers of persons who may have first hand knowledge of what happened to you or who may have seen or experienced similar treatment.

Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Home Phone:
What information can this witness provide?

Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Home Phone:
What information can this witness provide?

Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Home Phone:
What information can this witness provide?

10. REFUSAL INFORMATION
If refused a job, promotion, transfer, etc., please complete as many as you can:

Title of job sought:
How did you know about the job?
Did you apply verbally or by written application?
Verbally
Written Application
When and to whom did you submit your application?
Who got the job, promotion, transfer, etc.?
What reason was given for your denial?

11. REMEDY
What remedy relief are you seeking?

Attach any related files Here: