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Employment Discrimination Complaint Form
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Employment Discrimination Complaint Form
SECTION I
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
I,
*
being first duly sworn upon my oath affirm and hereby say: I have been given assurance by a representative of the FORT LAUDERDALE/BROWARD BRANCH OF THE NATIONAL ASSOCIATION FOR THE ADVANCEMENT OF COLORED PEOPLE (NAACP) that this Affidavit will be considered confidential by the NAACP and will not be disclosed as long as the case remains open unless it becomes necessary for the NAACP to produce the Affidavit in a formal proceeding. Upon the closing of this case, the Affidavit may be subject to disclosure in accordance with the policy of the Branch. Completing this form does not constitute filing an official complaint with a legal authority. At this time, the NAACP is only seeking information to assist you concerning this complaint.
Name
*
First
Middle
Last
Date of Birth
Sex
Male
Female
Email Address
*
Cell Phone Number
*
Home Phone
*
Work Phone Number
Race
Native Country
*
In what Country were you born?
Street Address
City
State
Zip Code
SECTION II
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
COMPLAINT OF DISCRIMINATION NON-EMPLOYMENT RELATED INCIDENTS DETAILS
IF YOU ARE ALLEDGING DISCRIMINATION, PLEASE CHECK ALL THAT APPLY:
Race Or Color
Religion
Religion
Sex
Age
Handicapped Status
IF YOU ARE ALLEDGING UNLAWFUL EMPLOYMENT PRACTICES, PLEASE CHECK ALL THAT APPLY:
Reprisal/Retaliation
Unlawful Hiring
Promotion
Firing
Wages/Salary/Pay
Other Terms And Conditions Of Employment
Pregnancy Discrimination Act
SECTION III
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
WHO DISCRIMINATED AGAINST YOU?
*
(Give full name/s of the individual/s and their job titles; also, the name and address of the Employer, Labor Organization, Employment Agency, Apprenticeship Committee, Licensing Agency, and its owner, President/CEO’s name; etc. List/name all)
Person's Full Name
Title
If Any, Other Parties Full Names
Title
Employer's Name
Employer's Street Address
City
State
Zip Code
Date / Time
Date
Time
Location of the incident
Detailed give detail information if different from the employer’s address
SECTION IV
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
Have You Filed A Complaint With Any Governmental Agency?
*
Choose One
No
Yes
If Yes, Which Ageny/ies, Give Date Filed?
Also briefly state the status of you filed complaint:
SECTION V
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
If Yes, Have You Filed an Internal Grievance Referencing This Complaint?
Name of Local & Representative or Name of Person with whom you submitted your complaint
Does the Employer Have a Union, Grievance or Fair-Hearing Process?
*
Choose One
No
Yes
Choose one
If no, why not?
Also, if you filed with the union, give the name of the Local and Representative.
SECTION VI
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
Have You Retained An Attorney Regarding This Case?
*
Choose One
No
Yes
Choose one
If Yes, Give Attorney’s Name, Address, Telephone, and Facsimile Numbers, and Date Retained.
PLEASE NOTE: The NAACP will NOT get involved unless/until your attorney is notified/informed by you that you have sought assistance of the NAACP. At that time your Attorney should address a letter of approval to the NAACP stipulating that he/she would like the NAACP’s assistance in this matter.
SECTION VII
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
If You Were Employed With This Company, What Date Did You Begin Your Employment?
Enter Employment date
Are You Still Employed With This Company?
*
Choose One
Yes
No
Choose one
If No, What Date Were You Terminated?
If not employed, have you filed for employment compensation?
*
Choose One
Yes
No
Choose one
Were you granted benefits?
*
Choose One
Yes
No
Choose one
Were you granted benefits?
SECTION VIII
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
Do You Have Evidence and/or Witnesses To Support Your Allegations?
*
Choose One
Yes
No
Choose one
If Yes…
For evidence, state what evidence you have (make sure the Branch has a copy). For witnesses, give witness (es) full name, address, and telephone number of each. Also, state to what each witness can/will attest.
SECTION IX
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
The Actual Date Or The Most Recent Date On Which This Discrimination Occured
Date
Time
SECTION X
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
Explain Briefly What Unfair incident Was Done to You
(Please State Pertinent Information Only):
SECTION XI
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
What Is/Was Your Previous/Last Job Title?
Is/Was This A Management/Supervisory Position?
*
Choose One
Yes
No
Choose one
How were you rated on your last three (3) performance appraisal reviews?
Choose One
Excellent/Exceeds expectations
Very Good/Meets expectations
Good/Average
Fair
Poor/Does not meet expectations
Other
Have You Ever Been Disciplined, Written-Up, Etc?
*
Choose One
Yes
No
Choose one
How Many Times:
Briefly Explain here
SECTION XII
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
How Do You Wish For The Fort Lauderdale/Broward Branch Of The NAACP To Help You With This Matter?
State Your Desired Results. Please Be Brief “To The Point” / “Specific.”
SECTION XIII
PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
I AFFIRM THAT I HAVE, ON MY OWN, MADE WRITTEN THE FOREGOING CHARGE AND HAVE HAD AMPLE OPPORTUNITY TO MAKE CORRECTIONS. ALSO, I AFFIRM THAT ALL OF THE INFORMATION AND STATEMENTS I SUPPLIED IN THIS COMPLAINT TO THE NAACP ARE FACTS, TRUE, AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF. FURTHER, I AFFIRM THAT NONE OF THE AFOREMENTIONED IS OF FABRICATED OR FRIVOLOUS NATURE. IN CONSIDERATION OF SUCH DISCLOSURE, I HEREBY RELEASE AND HOLD HARMLESS THE NAACP AND ANY OF ITS REPRESENTATIVES FROM ANY AND ALL LIABILITY WHICH MAY ARISE THEREFROM.
I,
The Complainant and undersigned, reside at:
By placing my initials to the left of each numbered item below and my signature at the end of this document, I affirm that I understand it and agree with it in full.
1. I have completed and submitted to THE FORT LAUDERDALE/BROWARD BRANCH NAACP a Complaint of Discrimination directed against:
Respondent’s Name
2. I understand that the NAACP is a private, non-profit, voluntary organization. It is not a government agency. Filing a complaint with the NAACP is not the same as filing a complaint with an administrative agency or filing a suit in a complaint with an administrative agency, or filing a lawsuit in a court of law. Whatever rights I have to file a complaint with an administrative agency or to file a civil lawsuit is completely unaffected by whether or not I have filed my complaint with the NAACP.
I agree
I disagree
3. The deadline by which I must file my complaint or lawsuit with the appropriate source is:
If I do not file my complaint or lawsuit by that time, I may have no right to a recovery from any harm from the Respondent.
4. I have authorized the NAACP to investigate my complaint, AND to attempt to mediate my complaint with Respondent and /or Respondent’s representatives in order to explore the possibility of settlement; AND if there is no settlement, to provide me with a referral list of lawyers who my consider representing me in litigation against the Respondent.
I agree
I disagree
5. I will provide the NAACP copies (not originals) of whatever documents I have to support the complaint. If I request in writing that some of the material held be in confidence, the NAACP will hold it in confidence; otherwise, the NAACP may share it with the Respondent(s) or with state or federal anti-discrimination agencies.
I agree
I disagree
6. If the NAACP mediates my complaint with Respondent, I will refrain from filing my complaint with a state or federal anti-discrimination agency, or filing a lawsuit while the mediation is in progress. However, I am free at any time, after notifying the NAACP of my intentions, to terminate the mediation and file my complaint with at state or federal antidiscrimination agency, or file a lawsuit. If the mediation is non-binding, I am not required to accept a settlement with the Respondent(s).
I agree
I disagree
7. I agree that if I accept a settlement with the Respondent(s), I will be required to sign a release of Claims against a Respondent(s), and I will honor the terms and conditions of such a Release and Claim.
I agree
I disagree
8. I understand that the NAACP is a Civil Rights Organization, not a law firm, and cannot provide me with legal advice or legal representation. Although some of its members and volunteers are lawyers, they represent the NAACP and not me personally.
I agree
I disagree
9. I release and hold harmless the NAACP, its officers, directors, employees, agents, personal actions and actions, cause and causes of action, suits, debts, dues, sums of money, accounts, reckonings, bonds, bills, specialties, covenants, contracts, controversies, agreement, promises, variances, trespasses, damages, judgments, executions, claims, and demands whosoever, in law in equity, which I ever had, may have in the future, or which any of my personal representative, successors, heirs or assigns hereinafter can, shall or may have against the NAACP, upon or by reason of the NAACP’s handling of my Complaint of Discrimination.
I agree
I disagree
Agreed by:
Dated:
Signature of Complainant:
Clear Signature
Witnessed by:
Print Name of NAACP Member/Volunteer
Signature of NAACP Member/Volunteer
Clear Signature
Date / Time
Date
Time
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