Office of Equal Opportunity
Employment Discrimination Intake Questionnaire

Welcome to the Office of Equal Opportunity.  We need you to provide us with certain basic information about the people (including you) and events that have caused you to contact our office.  This information will help us find out whether we can be of further help to you.

You can download this form or fill out the form online below.

Please provide the following information:

Your First Name * Your Middle Name Your Last Name * Date of Birth DateOfBirth Date   Street or Mailing Address * City * State * Zip Code * Home Phone * Cell/Other Phone Your Email Address   Please provide the following information about a person at a different address in your area who can always reach you. Name of Contact Person * Relationship * Phone Number * Street Address * City * State * Zip Code * Provide the following information about the company, business, etc. that you believe discriminated against you. Company Name * Telephone Street or Mailing Address * City * State * Zip Code * Provide the name and, if known, job title of the person who discriminated against you. If different than above, provide address, city, state, zip, and telephone. Name * Job Title * Telephone Street or Mailing Address (if different than above) City State Zipcode When did this happen? Provide the latest date of discrimination. If there is more than one date of discrimination, provide the latest and earliest dates. Latest Date * LatestDateOfDescrimination Date Earliest Date EarliestDateOfDescrimination Date Lee County Ordinance prohibits discrimination in employment based on: Race, Sex, Religion, Handicap, Retaliation, Color, Age (40+) and National Origin. Why did this happen? Do you believe this happened because of one or more of the bases listed above? If so, list below the basis or bases of this discrimination. Lee County Ordinance prohibits nearly all discriminatory practices in employment. Many employment discrimination charges involve one or more of the issues listed below: Discharge, Sexual Harrassment, Pay Differences, Lay Off / Recall, Failing to Hire, Harassment (Race, Age, etc.), Failing to Promote What happened? List below the issue or issues (whether or not listed above) that apply to the discrimination you experienced. In addition to this form, prepare a chronology of incidents that lists in date order the incidents that caused you to contact this office. This chronology must include the date of each incident and a detailed description of the incident. When more than once incident occurs on the same date, please provide the time of each incident. We will accept your best guess as to dates and times. If unsure, simply write a date or time is approximate. If there are any witnesses to any of the incidents, please provide a list by name, phone number, or other contact information (address, email address, etc.). When you have this entire package completed, please call to make an appointment. What Happened? * Check this box if the company fired you and answer the questions that will appear below. Termination Section If the company fired you, please answer the questions below. Job title when you were fired? How long in that job? With the company? Who fired you?   Give us the name and job title of the person who fired you. Name Job Title Why did they fire you? Write below what the person listed above told you when she or he terminated you. If they gave you anything in writing, you should send or bring this to our office. Why did they fire you? Was the person who fired you told to do so by someone else? If so, give us the name and job title of this person. Name Job Title Is the reason for your termination false? Yes No If you chose "Yes" above, please explain why you believe the reason(s) for your termination is / are false. Who replaced you, if anyone?   If you know, give us the name of the person who took your place. Who replaced you? Do you know of anyone who did the same thing? Yes No If you checked "Yes" above, list below the name and, if known, job title of the persons who did the same thing. For each person, tell what happened to them. Name   Job   Title What   Happened? Check this box if the company did not hire or promote you and answer the questions that will appear below. Failure to Hire / Promote Section If the company did not hire or promote you, please answer the questions below. Name of job you sought? How did you learn about the job? Newspaper, friend, Job Service, etc.? Please specify source. If you have a copy of any written notice regarding this job, (classified ad, job notice, etc.) please send a copy to our office. How did you learn about the job? Date(s) you learned about the job? FailureToHireDateLearned1 Date FailureToHireDateLearned2 Date Date(s) you applied for the job? FailureToHireDateApplied1 Date FailureToHireDateApplied2 Date How did you apply for the job? (choose all of the below that apply.) If you have a copy of any application, resume, or other documents your attempt to seek work with this company, please send copies of those to our office. How did you apply for this job? Application Resume Phone Call Talked With Company Official What are the work experience or education requirements for this job? List them below if you know of any. If you have any documents such as a job description, classified ad, etc. that lists these requirements please send a copy to our office. Experience and Education Requirements Do you know who made the decision to not hire or promote you? Yes No If you selected 'Yes" above what is their name? Job Title Do you know who got the job? Yes No Name   Date   hired / promoted FailureToHireDateOfHiredPromotedPerson1 Date FailureToHireDateOfHiredPromotedPerson2 Date   FailureToHireDateOfHiredPromotedPerson3 Date   Did the company give you a reason why they did not hire you? Yes No If you selected "Yes" above, tell us the reason the company gave you for not hiring or promoting you. If you have any documents giving a reason for not hiring you, please send copies to our office. Why do you believe the company did not hire or promote you because of the basis or bases you specified previously?