Please provide the name of an individual at a different address in your
local area who would know how to reach you:
* State briefly: What action was taken against you that you believe
to be discriminatory? Indicate the harm, if any, caused to you or others in your
work situation, as a result of such action.
* State briefly: Why do you believe this action was taken against you? It is a violation of the law to deny you your rights for any of the following bases: Race, Color, National Origin, Sex, Religion, Sexual Orientation, Gender Identity/Expression, Age, Disability, Marital Status, Familial Status (families with children under 18) or Retaliation (retaliation based on a protected activity).
Provide the name, address and telephone number of the employer, union
(give local number), and / or employment agency that you
believe discriminated against you.
* What was the most recent date your alleged harm took place? (mm/dd/yyyy):
Normally, your identity as a Complainant will be disclosed to the organization which allegedly discriminated against you. Consent
Have you sought assistance about the action you think was discriminatory
from any agency, an attorney, EEOC, the Florida Commission on Human Relations
(FCHR) or from any other source?
Name of Assistance Source:
Result if Any:
Have you filed, in the past, an employment discrimination complaint with the
EEOC, FCHR, Tampa
Office of Human Rights or or another local agency comparable to the Tampa Human
Complaint Filed With:
Name of Company Filed Against:
Complaint Number (if known):
Approximate Date Filed:
PRIVACY ACT STATEMENT: This form is covered by the Privacy Act of 1974;
Public Law 93-579 Filling out and bring or sending us this questionnaire does not mean that
you have filed a charge. Once you have submitted the
completed form, you will be contacted by our office within 10 days. If you
are not contacted in 10 days please call (813) 274-5835. Please be
advised that there are time limits to file a charge, generally within 180 days
or in some jurisdictions one (1) year of the alleged harm.
Office Mailing Address: 306 E. Jackson Street, 3N , Tampa, Florida, 33602
If you need an accommodation under the Americans with Disabilities Act to
complete the questionnaire, please call (813) 274-5835
NOTE: You can upload attachments after submitting this form.
When you submit this form, you will receive a Tracking Number and Access Key allowing you to follow-up on this submittal.
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