This legal template includes 17 fields. Formal complaint form for filing workplace discrimination claims with legal counsel. Free to customize and use on ZenBuild.
Complainant Name (text, required)
Email (email, required)
Phone Number (text, required)
Employer Name (text, required)
Employer Address (text, required)
Job Title (text, required)
Years Employed (number, required)
Basis of Discrimination (dropdown selection, required) — options: Race, Color, National Origin, Sex/Gender, Age (40+), Disability, Religion, Pregnancy, Sexual Orientation, Gender Identity, Genetic Information
Type of Discrimination (dropdown selection, required) — options: Hiring/Termination, Promotion Denial, Pay Inequality, Harassment, Hostile Work Environment, Retaliation, Reasonable Accommodation Denial, Segregation
Date(s) of Discriminatory Acts (text, required)
Detailed Description of Events (long text, required)
Name(s) of Discriminators (text, optional)
Reported to HR/Management (multiple choice, required) — options: Yes, No
Date of Internal Report (text, optional)
Filed with EEOC/State Agency (multiple choice, required) — options: Yes, No, Planning To
