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Fillable Form EEOC Intake Questionnaire

This questionnaire will help U.S. EEOC look at your situation and figure out if you are covered by the laws they enforce.

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What is the EEOC Intake Questionnaire?

The EEOC Intake Questionnaire is a form by the U.S. Equal Employment Opportunity Commission (EEOC). A professional uses it if he or she plans to file a charge against or sue his or her employer in court.

The EEOC Intake Questionnaire is a four-page document. If you are the one filing it, it requires that you answer all the questions as completely and accurately as possible, as the information you will provide will enable the EEOC office to determine if your situation is covered by the laws they enforce or not. You may attach additional pages or documents to complete your responses.

To get information about the laws that the EEOC enforces and the charge -filing procedures, you may visit their official website at eeoc.gov.

How to fill out the EEOC Intake Questionnaire?

Provide all the required information completely. If you do not have an answer to any of the questions, you may write “not known.” For any questions that are not applicable, write “n/a.”

1. Personal Information
The first part of this section requires your personal information such as your full legal name, complete mailing address, contact numbers, including your work number, email address, and date of birth.

For your sex, choose if you are a male or a female.

Mark the appropriate checkbox to answer if you have a disability or not.

For the ii section, determine your race. Mark the appropriate checkbox to determine if you are American Indian or Alaska Native, Asian, White, Black or African American, Native Hawaiian, or Other Pacific Islander.

The iii section asks for your National Origin or the country of origin or ancestry.

You also need to provide the full legal name, current address, and your relationship with the person the EEOC can contact if they are unable to reach you.

2. I believe that I was discriminated against by the following organization
This section asks you to mark the checkbox to determine the party that committed the discrimination. You may select Employer, Union, Employment Agency, or Other. For other, please specify.

Then, provide the name of the organization, its complete address, phone number, type of business, the job location if different from the Organization Address, Human Resources Director or the name of the owner, and his or her phone number.

Mark the appropriate checkbox that determines the number of employees in the organization at all locations.

3. Your Employment Data
Select the appropriate checkbox to determine if you are a Federal Employee or not.

Provide the date you were hired, job title at hire, pay rate when hired, last or current pay rate, job title at the time of alleged discrimination, date when you quit or got discharged, and the name and title of your immediate supervisor.

If the discrimination happened during a job application, provide the date you applied for the job and the job title you applied for.

4. What is the reason (basis) for your claim of employment discrimination?
Check all the bases for your claim of employment discrimination that apply. You may select Race, Sex, Age, Disability, National Origin, Religion, Retaliation, Pregnancy, Color or a difference in skin shade within the same race, and Genetic Information.

If you marked the Genetic Information checkbox, select the type of genetic information involved. You may select genetic testing, family medical history, or genetic services. You may select more than one type.

If you marked the color, religion, or national origin checkbox, specify which.

If you checked genetic information, detail how the employer obtained the genetic information.

For other reasons for discrimination, provide an explanation in the provided space.

5. What happened to you that you believe was discriminatory?
In the appropriate spaces, provide the dates of harm, the actions, and the name of the person or names of people who you believe discriminated against you and his or her title or their titles. You may attach additional pages if needed.

6. Why do you believe these actions were discriminatory?
Provide a detailed explanation of why you believe the actions committed were discriminatory. You may use additional pages if needed.

7. What reason(s) were given to you for the acts you consider discriminatory? By whom? His or Her Job Title?
Answer the questions as completely and honestly as possible.

8. Describe who was in the same or similar situation as you and how they were treated.
There are three parts to this section — details of the people who were treated better, worse, and the same as you. Provide all the asked information including their full legal name, race, sex, age, national origin, religion, or disability, job titles, and the descriptions of how they were treated. Answer the parts appropriately.

Only answer items 9 to 12 if you are claiming discrimination based on disability. Otherwise, skip to item 13.

9. Please check that apply
Mark the appropriate box to determine if you have a disability, do not have a disability now but had one, do not have a disability but the organization treats you as if you are disabled.

10. What is the disability that you believe is the reason for the adverse action taken against you? Does this disability prevent or limit you from doing anything?
Answer the questions as honestly as possible. For the limitations, provide information if your disability prevents or limits you from doing common actions including lifting, sleeping, breathing, walking, caring for yourself, or working.

11. Do you use medications, medical equipment, or anything else to lessen or eliminate the symptoms of your disability?
Select “Yes” or “No.” If yes, provide the information on the medication, medical equipment, or other assistance you use.

12. Did you ask your employer for any changes or assistance to do your job because of your disability?
Select “Yes” or “No.” If yes, provide the date when you asked and the method of asking, whether verbally or in writing. Also, provide the full legal name and the job title of the person you asked, describe the changes or assistance that you asked for, and detail how your employer responded to your request.

13. Are there any witnesses to the alleged discriminatory incidents? If yes, please identify them below and tell us what they will say.
Provide the full legal names, job titles, and contact information of the witnesses. Provide what you believe they would say to the EEOC.

14. Have you filed a charge previously in this matter with EEOC or another agency?
Select “Yes” or “No.”

15. If you have filed a complaint with another agency, provide name of agency and date of filing
Provide the required information.

16. Have you sought help about this situation from a union, an attorney, or any other source?
Select “Yes” or “No.” Provide the name of the organization, the name of the person you spoke with, and the date of contact. Provide results, if applicable.

Mark the checkboxes to determine what you would like the EEOC to do with the information you are providing on the questionnaire.

Lastly, sign and date the form.

Submission

Filing the EEOC Intake Questionnaire does not mean that you have filed a charge. By submitting this to the EEOC office, you will be informed if your situation is covered by the laws they enforce. You may bring or mail this form to the EEOC office. You may visit the official EEOC website to find the field office with jurisdiction over your area.

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