Employment Discrimination Complaint Form
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2EMPLOYMENT DISCRIMINATION COMPLAINT FORM
TWCCRD#________________
Texas Workforce Commission Civil Rights Division
Please return this form by:
Mail: 101 East 15th Street, #144T, Austin, TX 78778-0001
EEOC#____________________
Email:
EEOIntake@twc.state.tx.us
Telephone: (888) 452-4778 or
Fax: (512) 463-2643 (Please include a cover sheet with your name and the total # of pages included.)
DATE RECEIVED (For Office Use Only):
Please indicate if you have previously filed this complaint with any
of the agencies below:
Texas Workforce Commission Civil Rights Division (TWCCRD)
Equal Employment Opportunity Commission (EEOC)
City of Austin Equal Employment and Fair Housing Office
Corpus Christi Human Relations Division
Fort Worth Human Relations Department
Please be sure you provide all the information requested. For Assistance, send an E-mail to
EEOIntake@twc.state.tx.us
or call
(888) 452-4778. (Ofrecemos asistencia en Español)
Complainant Full Name:
Complainant Representative (Optional): (If you are represented by an attorney,
please have them submit a letter of representation):
Address Line 1:
Address Line 1:
Address Line 2:
Address Line 2:
City/State/Zip:
City/State/Zip:
Home Phone #:
Phone #:
Other Phone #:
Fax #:
Email:
Preferred Form of Contact: (Please check)
E-mail
Telephone
Date Hired:
Position held:
HR Personnel Officer/EEO Officer/or Highest Ranking Officer on work site:
Still employed?
Yes
No
15 or more employees:
Name of Employer (Please be sure to give the complete Company
Yes
No
name and address where you physically worked)
Address Line 1:
Address Line 1:
Address Line 2:
Address Line 2:
City/State/Zip:
City/State/Zip:
Phone#:
Phone#:
BASIS: I believe I have been
Color (Based on skin color):
Age (You must be
Disability:
discriminated against in violation of
Black
Disabled
40 years of age or older
state law (Texas Labor Code, Chapter
Brown
History of disability
to qualify):
21) and federal law (ADEA, GINA, Title
Date of Birth:
White
Regarded as disabled
VII, ADAAA), as follows:
____ /______/_____
Other ____________
(Pregnancy is NOT a disability unless
Month/day/year
you are regarded as disabled.)
Age at time of incident:
GINA
Please mark only the basis
National Origin:
Race:
(Genetic Information
African-American
American Indian/Alaskan Native
you believe were the reasons
Non-discrimination
Anglo/Caucasian
Asian/Pacific Islander
you were discriminated.
Act)
East Indian
Black
Hispanic
White
Mexican
Other ____________
Other ___________
EXAMPLE: If your treatment
Religion:
Retaliation:
Sex:
was because of your race, then
Baptist
Assisted another filing
Female
Catholic
discrimination
Female/Pregnancy
check only the box by your race.
Jewish
Filed a complaint of
Male
Muslim
discrimination
Other
Participated in discrimination
_____________
investigation
ON THIS DATE:
____ /______/_____
(Month/Day/Year)
Form 1000
Revised: 09/19/2014
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