ࡱ>  bjbj 4{{//8l7)8E E E E (,,.$7&7&7&7&7&7&7$9s<BJ7/("(//J7//E E =7555/4/8E E $75/$755g5E 0a0(5770)85=B0z=5=5T//5/////J7J75///)8////=///////// : EMPLOYMENT DISCRIMINATION COMPLAINT FORM Texas Workforce Commission Civil Rights Division Please return this form by: Mail: 101 East 15th Street, #144T, Austin, TX 78778-0001 Email:  HYPERLINK "mailto:EEOIntake@twc.state.tx.us" 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.) TWCCRD#________________ EEOC#____________________ Please indicate if you have previously filed this complaint with any of the agencies below:  FORMCHECKBOX Texas Workforce Commission Civil Rights Division (TWCCRD)  FORMCHECKBOX Equal Employment Opportunity Commission (EEOC)  FORMCHECKBOX City of Austin Equal Employment and Fair Housing Office  FORMCHECKBOX Corpus Christi Human Relations Division  FORMCHECKBOX Fort Worth Human Relations DepartmentDATE RECEIVED (For Office Use Only): Please be sure you provide all the information requested. For Assistance, send an E-mail to  HYPERLINK "mailto:EEOIntake@twc.state.tx.us" EEOIntake@twc.state.tx.us or call us at (888) 452-4778. (Ofrecemos asistencia en Espaol)Complainant Full Name:  FORMTEXT       Complainant Representative (Optional): (If you are represented by an attorney, please have them submit a letter of representation):  FORMTEXT       Address Line 1:  FORMTEXT       Address Line 1:  FORMTEXT      Address Line 2:  FORMTEXT       Address Line 2:  FORMTEXT      City/State/Zip:  FORMTEXT        FORMTEXT        FORMTEXT       City/State/Zip:  FORMTEXT        FORMTEXT        FORMTEXT      Home Phone #:  FORMTEXT       Phone #:  FORMTEXT      Other Phone #:  FORMTEXT       Fax #:  FORMTEXT       Email: Preferred Form of Contact: (Please check)  FORMCHECKBOX  E-mail  FORMCHECKBOX  Telephone Date Hired:  FORMTEXT       Position held:  FORMTEXT       Still employed?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoHR Personnel Officer/EEO Officer/or Highest Ranking Officer on work site:  FORMTEXT      Name of Employer (Please be sure to give the complete Company name and address where you physically worked)  FORMTEXT      15 or more employees:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Address Line 1:  FORMTEXT      Address Line 1:  FORMTEXT       Address Line 2:  FORMTEXT      Address Line 2:  FORMTEXT      City/State/Zip:  FORMTEXT        FORMTEXT        FORMTEXT      City/State/Zip:  FORMTEXT        FORMTEXT        FORMTEXT      Phone#:  FORMTEXT       Phone#:  FORMTEXT       BASIS: I believe I have been discriminated against in violation of state law (Texas Labor Code, Chapter 21) and federal law (ADEA, GINA, Title VII, ADAAA), as follows:  FORMCHECKBOX Age (You must be 40 years of age or older to qualify): Date of Birth: ____ /______/_____ Month/day/year Age at time of incident:  FORMTEXT       FORMCHECKBOX Color (Based on skin color):  FORMCHECKBOX Black  FORMCHECKBOX Brown  FORMCHECKBOX White  FORMCHECKBOX Other ____________  FORMCHECKBOX Disability:  FORMCHECKBOX Disabled  FORMCHECKBOX History of disability  FORMCHECKBOX Regarded as disabled (Pregnancy is NOT a disability unless you are regarded as disabled.) Please mark only the basis you believe were the reasons you were discriminated. FORMCHECKBOX GINA (Genetic Information Non-discrimination Act)  FORMCHECKBOX National Origin:  FORMCHECKBOX African-American  FORMCHECKBOX Anglo/Caucasian  FORMCHECKBOX East Indian  FORMCHECKBOX Hispanic  FORMCHECKBOX Mexican  FORMCHECKBOX Other ___________ FORMCHECKBOX Race:  FORMCHECKBOX American Indian/Alaskan Native  FORMCHECKBOX Asian/Pacific Islander  FORMCHECKBOX Black  FORMCHECKBOX White  FORMCHECKBOX Other ____________EXAMPLE: If your treatment was because of your race, then check only the box by your race. FORMCHECKBOX Religion:  FORMCHECKBOX Baptist  FORMCHECKBOX Catholic  FORMCHECKBOX Jewish  FORMCHECKBOX Muslim  FORMCHECKBOX Other _____________ FORMCHECKBOX Retaliation:  FORMCHECKBOX Assisted another filing discrimination  FORMCHECKBOX Filed a complaint of discrimination  FORMCHECKBOX Participated in discrimination investigation. ON THIS DATE: ____ /______/_____ (Month/Day/Year) FORMCHECKBOX Sex:  FORMCHECKBOX Female  FORMCHECKBOX Female/Pregnancy  FORMCHECKBOX Male Form 1000 Revised: 09/03/2014 Employment Harms or Actions (Mark all that apply) FORMCHECKBOX Demotion (D1)  FORMCHECKBOX Discharge (D2)  FORMCHECKBOX Discipline (D3)  FORMCHECKBOX Harassment (H1)  FORMCHECKBOX Hiring (H2)  FORMCHECKBOX Layoff (L1)  FORMCHECKBOX Promotion (P3)  FORMCHECKBOX Reasonable Accommodation (R6)  FORMCHECKBOX Severance Pay (B5)  FORMCHECKBOX Sexual Harassment (S4) FORMCHECKBOX Suspension (S5)  FORMCHECKBOX Terms & Conditions (T2)  FORMCHECKBOX Training (T4)  FORMCHECKBOX Wages (W1)  FORMCHECKBOX Other: ________________________ FORMTEXT Z      ! 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lap(ytU#####$;$<$Z${$$$$%www $Ifgd $Ifgd$vkdih$$Ifl- .  t 0 .44 lap ytU ################## $ $ $ $$$,$ôôôôôôrô_PhUhCJOJQJaJ%jhUhCJOJQJUaJ+jDkhUh,sCJOJQJUaJ+jjhUh,sCJOJQJUaJ+jihUh,sCJOJQJUaJhUhCJOJQJaJ%jhUhzCJOJQJUaJ%jhUh,sCJOJQJUaJ+jihUh,sCJOJQJUaJ,$-$.$/$<$=$K$L$M$N$Z$[$i$j$k$l${$|$$$$$$$$$ô|֡f֡P֡ô+jRnhUh,sCJOJQJUaJ+jmhUh,sCJOJQJUaJ+jlhUh,sCJOJQJUaJhUhCJOJQJaJ%jhUhzCJOJQJUaJhUhCJOJQJaJ%jhUhCJOJQJUaJ%jhUh,sCJOJQJUaJ+jlhUh,sCJOJQJUaJ$$$$$$$$$$$$ % % % %%%,%-%.%/%G%H%V%ô|֡f֡P֡+jqhUh,sCJOJQJUaJ+jphUh,sCJOJQJUaJ+jphUh,sCJOJQJUaJhUhCJOJQJaJ%jhUhzCJOJQJUaJhUhCJOJQJaJ%jhUhCJOJQJUaJ%jhUh,sCJOJQJUaJ+j>ohUh,sCJOJQJUaJ%G%g%%Ī~WKK $$Ifa$gdUkd\v$$IflF -, 0 t0 .    44 lapytU $Ifgd$V%W%X%Y%g%h%v%w%x%y%%%%%%%%%%%%& ôôôôôyôcaHô0jhUhCJOJQJUaJmHnHuU+jpuhUhzCJOJQJUaJhUh 8CJOJQJaJ+jzthUh,sCJOJQJUaJ+jshUh,sCJOJQJUaJhUhCJOJQJaJ%jhUhzCJOJQJUaJ%jhUh,sCJOJQJUaJ+jrhUh,sCJOJQJUaJ      The following questions are regarding the employment harms or actions taken against you. (Each incident must be within 180 days of the date you submit your complaint to the TWCCRD.)DATE(S) DISCRIMINATION TOOK PLACE (Month/Day/Year) Earliest (Month/Day/Year) Latest (Month/Day/Year)  FORMCHECKBOX  CONTINUING ACTION Name and Position Title of person(s) who did the harm: (If filing under race, color, national origin, religion, sex, age, please provide the race, color, national origin, religion, sex, or age of the person(s) discriminating against you:) Did you complain of discrimination to your employer?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, date of complaint: ____ /______/_____ (Month/Day/Year) Name and Position Title of person(s) you complained to: Explain why you believe the employment harm(s) and/or action(s) were discriminatory: Employer s reason for its action: Are there other employees treated more fairly than you?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, please provide the information below: Full Name and Position Title (If filing under race, color, national origin, religion, sex, and/or age, please provide the race, color, national origin, religion, sex, or age of the person(s) treated more fairly than you.  What are you seeking as a resolution to your case? 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DText10JIf you will be represented by an individual/attorney, provide their name. $$If!vh55P#v#vP:V l; t0 .55PpytUDText2BProvide address Line 1 to include your street address or P.O. Box.DText119Provide your representative's street address or P.O. Box.$$If!vh55P#v#vP:V l t0 .55PpytUDText3"Provide address Line 2, if needed.DText12/Second Line for Address Information, if needed.$$If!vh55P#v#vP:V l t0 .55PpytUDText4Provide the city name.DText5$Provide the state in which you live.DText6&Provide your mailing address zip code.DText13+Provide Representative's city address name.DText14#Provide the representative's state.DText156Provide the representative's mailing address zip code.$$If!vh55P#v#vP:V l t0 .55PpytUDText74Provide your home phone number to include area code.DText16CProvide the representative's phone number to include the area code.$$If!vh55P#v#vP:V l t0 .55P/ pytUDText8HProvide another phone number to include area code, if you would like to.DText17AProvide the representative's fax number to include the area code.$$If!vh5} 5S 5P#v} #vS #vP:V l4 t0 .+5} 5S 5P/ / / pytU$$If!vh5} 5S 5P#v} #vS #vP:V l4 t0 .+5} 5S 5P/ / / pytUDCheck457Check this box if the company has 15 or more employees.DCheck469Check this box if the company has less than 15 employees.$$If!vh55P#v#vP:V l;  t 0 .55PpytUDText18/Provide the date you were hired by the company.DText199Provide the name of the position you held while employed.DeCheck438Check this box if you are still employed at the company.DeCheck44<Check this box if you are no longer employed at the company.TDText25oProvide the name of the Company's HR Personnel Officer/EEO Officer/or Highest Ranking Officer on the work site.$$If!vh55P#v#vP:V l  t 0 .55PpytUDText20complaint may be dismissed.Provide the name of the company you want to file your discrimination complaint against. The name must be complete/correct or yourDCheck457Check this box if the company has 15 or more employees.DCheck469Check this box if the company has less than 15 employees.$$If!vh55P#v#vP:V l t0 .55PpytUxDText21Provide the street address or P.O. Box for the company. The address must be complete/correct or your complaint may be dismissed.DText26>Provide the street address of P.O. Box of the Company Officer.$$If!vh55P#v#vP:V l t0 .55PpytUDText22CAdditional Line provide for company address. Please use if needed.DText27GSecond Line for Address Information, if needed for the Company Officer.$$If!vh55P#v#vP:V l t0 .55PpytU^DText23tProvide the name of the city the company you are filing against is located in. This is part of the company address.2DText33^Provide the name of the state the company is located in. This is part of the company address.DText34'Provide the company's address zip code.^DText23tProvide the name of the city the company you are filing against is located in. This is part of the company address.2DText33^Provide the name of the state the company is located in. This is part of the company address.DText34'Provide the company's address zip code.$$If!vh55P#v#vP:V lC t0 .55PpytUxDText21Provide the street address or P.O. Box for the company. The address must be complete/correct or your complaint may be dismissed.DText27GSecond Line for Address Information, if needed for the Company Officer.$IfK$L$l!vh5d5^#vd#v^:V l t0,5d5^/ / /  / pytU$IfK$L$l!vh5d5^#vd#v^:V l t0,5d5^/ / /  / pytU$$If!vh5 .#v .:V l t0 .5 .p ytUdDeCheck62wPlease check this box if you believe you have been discriminated against because of your age, 40 years of age or older.DText51-Provide your age of the time of the incident.:DeCheck67bCheck this box if you believe you have been discriminated against based on the color of your skin.DeCheck27ACheck this box if the discrimination is due to your color, Black.DeCheck28ACheck this box if the discrimination is due to your color, Brown.DeCheck26ACheck this box if the discrimination is due to your color, White..DeCheck29\Check this box if the discrimination is due to your color other than White, Black, or Brown.DCheck68are regarded as disabled.Check this box if you believe you have been discriminated against because of your disability. Pregnancy is not a disability unless you DeCheck31DCheck this box if the discrimination is due to a current disability.DeCheck33LCheck this box if the discrimination is due to your history of a disability.(DeCheck32YCheck this box if the discrimination is due to you being regarded as having a disability.$$If!vh5` 5p5@ 5#v` #vp#v@ #v:V lw t0 .5` 5p5@ 5p(ytU@DeCheck18eCheck this box if you believe you have been discrimiated against because of your genetic information.:DeCheck64bCheck this box if you believe you have been discriminated against because of your national origin. DeCheck9VCheck this box if the discrimination is due to your national origin, African-American.DeCheck8UCheck this box if the discrimination is due to your national origin, Anglo/Caucasian.DeCheck12QCheck this box if the discrimination is due to your national origin, East Indian.DeCheck10NCheck this box if the discrimination is due to your national origin, Hispanic.DeCheck11MCheck this box if the discrimination is due to your national origin, Mexican. DeCheck13KCheck this box if the discrimination is due to your national origin, Other.$DCheck63WCheck this box if you believe you have been discriminated against because of your race.*DeCheck6[Check this box if the discrimination is due to your race, American Indian orAlaskan Native.DeCheck5QCheck this box if the discrimination is due to your race, Asian/Pacific Islander.DeCheck4@Check this box if the discrimination is due to your race, Black.DeCheck3@Check this box if the discrimination is due to your race, White. DeCheck13KCheck this box if the discrimination is due to your national origin, Other.$$If!vh5` 5p5@ 5#v` #vp#v@ #v:V l t0 .5` 5p5@ 5/ p(ytU,DeCheck66[Check this box if you believe you have been discriminated against because of your religion.DeCheck20FCheck this box if the discrimination is due to your religion, Baptist.DeCheck21GCheck this box if the discrimination is due to your religion, Catholic.DeCheck22ECheck this box if the discrimination is due to your religion, Jewish.DeCheck23ECheck this box if the discrimination is due to your religion, Muslim.DeCheck24DCheck this box if the discrimination is due to your religion, Other.DeCheck69?Check this box if you believe you have been retaliated against.^DeCheck36tCheck this box if the discrimination is in retaliation for having assisted another individual filing discrimination.\DeCheck35sCheck this box if the discrimination is in retaliation for you having filed a previous complaint of discrimination.`DeCheck37uCheck this box if the discrimination is in retaliation for having participated in an investigation of discrimination."DeCheck65VCheck this box if you believe you have been discriminated against because of your sex.DeCheck16@Check this box if the discrimination is due to your sex, female. DeCheck17JCheck this box if the discrimination is due to your sex, female/pregnancy.DeCheck15:Check this box if discrimination is due to your sex, male.$$If!vh5` 5p5@ 5#v` #vp#v@ #v:V l t0 .5` 5p5@ 5/ p(ytU$$If!vh5 .#v .:V l  t 0 .5 .p ytUDeCheck48#Check this box if you were demoted.DeCheck49&Check this box if you were discharged.DeCheck50'Check this box if you were disciplined.DeCheck51$Check this box if you were harassed.DeCheck52%Check this box if you were not hired.DeCheck53$Check this box if you were laid off.DeCheck54.Check this box if you were denied a promotion.DeCheck55;Check this box if you were denied reasonable accommodation.DeCheck470Check this box if you were denied severance pay.DeCheck56-Check this box if you were sexually harassed.DeCheck57%Check this box if you were suspended. 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Arial Narrow7.@Calibri5. .[`)TahomaA$BCambria Math"qh6' 7g*'g-2M4qn20NHX  $P2!xx(Employment Discrimination Complaint Form(Employment Discrimination Complaint Form(Employment Discrimination Complaint Form Lopez, AndresnguyendOh+'0L` p|    ,Employment Discrimination Complaint Form,Employment Discrimination Complaint FormLopez, Andres,Employment Discrimination Complaint Form Normal.dotmnguyend3Microsoft Office Word@F#@dg@.@L-՜.+,D՜.+,L px  -Equal OpportunityTexas Workforce Commission2 )Employment Discrimination Complaint Form Title< 8@ _PID_HLINKSA cK!mailto:EEOIntake@twc.state.tx.uscK!mailto:EEOIntake@twc.state.tx.us  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxz{|}~Root Entry FdaData y`1Table=WordDocument 4SummaryInformation(DocumentSummaryInformation8MsoDataStorep a0aXL3EWUENNVO4==2p a0aItem  PropertiesUCompObj y   F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q