Employment Discrimination Complaint Form Page 2
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2Employment Harms or Actions (Mark all that apply)
Demotion (D1)
Layoff (L1)
Suspension (S5)
Discharge (D2)
Promotion (P3)
Terms & Conditions (T2)
Discipline (D3)
Reasonable Accommodation (R6)
Training (T4)
Harassment (H1)
Severance Pay (B5)
Wages (W1)
Hiring (H2)
Sexual Harassment (S4)
Other: ________________________
The following questions are regarding the employment harms or actions taken against you.
(Each incident must be within 180 days of the date you submit your complaint to the TWCCRD.)
DATE(S) DISCRIMINATION TOOK PLACE (Month/Day/Year)
Earliest (Month/Day/Year)
Latest (Month/Day/Year)
CONTINUING ACTION
Name and Position Title of person(s) who did the harm:
(If filing under race, color, national origin, religion, sex, age,
please provide the race, color, national origin, religion, sex, or age of the person(s)
discriminating against you:)
Did you complain of discrimination to your employer?
Yes
No
If Yes, date of complaint: ____ /______/_____ (Month/Day/Year)
Name and Position Title of person(s) you complained to:
Explain why you believe the employment harm(s) and/or action(s) were discriminatory:
Employer’s reason for its action(s):
Poor Work Performance
Other (please list)
________________________________________________________________________
Theft/Embezzlement
Undue Hardship
________________________________________________________________________
Work Conduct
Workplace Violence
________________________________________________________________________
Are there other employees treated more fairly than you?
Yes
No
If Yes, please provide the information below:
Full Name and Position Title
(If filing under race, color, national origin, religion, sex, and/or age, please
provide the race, color, national origin, religion, sex, or age of the person(s) treated
more fairly than you.
What are you seeking as a resolution to your case?
____________________________________________________________________________________________
______________________________
Signature
Date
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