Employment Discrimination Claim Form
Your Information
Full Name
Address
Phone Number
Email Address
Employer Information
Employer Name
Employer Address
Employer Phone Number
Claim Details
Position Held
Date of Hire
Date of Incident
Type of Discrimination
Race
Color
National Origin
Sex
Religion
Disability
Age
Pregnancy
Other
Description of Incident
Witnesses (if any)
Resolution Sought
Please describe what outcome or resolution you are seeking
Signature
Date