Discrimination Complaint Form - Illinois Department Of Commerce And Economic Opportunity
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1
2State of Illinois
Illinois Department of Commerce and Economic Opportunity
Workforce Innovation and Opportunity Act
Discrimination Complaint Form
Complainant’s Name:
_______________________ Status of Complainant: (check one)
Address:
_______________________
Employee:
_______________________
Applicant:
Phone:
_______________________
Participant:
Email:
_______________________
Other:
Respondent’s Name:
_______________________
Status of Respondent (s):
Position:
_______________________
Service Provider:
Address:
_______________________
Adm. Entity:
_______________________
Grant Recipient:
Phone Number:
_______________________
Private Employer:
Respondent’s Name:
_______________________
Position:
_______________________
Address:
_______________________
_______________________
Phone Number:
_______________________
Basis of Complaint Alleged
Has a charge been filed with? (Please circle)
Race: Specify______________________
Yes No IL Dept. Of Rehab Services
Color: Specify______________________
Yes No IL Dept. Of Human Rights
Religion: Specify______________________
Yes No US Department of Labor
National Origin: Specify_________________
Yes No US Equal Employment
Sex: Circle Male/Female
Opportunity Commission
Age: Specify Date of Birth _________________
Disability: Specify ______________________
Political Affiliation or Belief: Specify ______________
Citizenship: Specify ______________________
Sexual Harassment: Specify_____________________
Sexual Orientation: Specify______________________
Pregnancy: Specify__________________________
Retaliation: Specify__________________________
To the best of your knowledge, what date(s), times(s) and place(s) did the alleged complaint(s) occur? (if
applicable)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Parent category: Legal