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Full-Time Part-Time Approximate Number of Employees at the Company (company-wide) 1-14 15-49 50-99 100+ Discriminatory Conduct ReviewWhat type(s) of discrimination do you believe occurred? (Check all that apply) * Color National Origin Sex (*including pregnancy, sexual orientation, gender idenity) Race Religion Age (over 40) Disability Retaliation for opposing discrimination Retaliation for Complaining about discrimination Other Who was responsible for the discrimination or harassment??What Specific Discriminatory Acts Occured??Date(s) the conduct occured (or date of most recent incident) Date of most recent incident of discrimination Where any witnesses present? If so, list their names and roles:Did you report the discrimination or harassment to anyone at the company? Yes No If yes, to whom and when?What was the response, if any, resulting from your reporting?Have you experienced any of the following as a result of the discrimination? (check all that apply) * Termination Demotion Denied Promotion Harassment Reduced Hours of Pay Transferred Hostile work environment Other If other, Please explainWhat Release (if any) did your employer give for the adverse action?Prior Filings / TimelineHave you filed a charge with the EEOC or the Texas Workforce Commission (TWC)? * Yes No If yes, date of filing: Status of the ChargeDid you receive a undefinedright to sueundefined letter from any government entity? Yes No If you have received a undefinedright to sueundefined Letter, please provide the date it was issued by the agency. Have you previously filed a grievence, complaint or lawsuit regarding this matter? Yes No If yes, please provide details:Do you have any of the following documents? (Check all that apply) * Employment contract or offer letter Pay stubs/pay records Disciplinary records emails, texts, or written communication related to the claim witness statements employee handbook or policies EEOC/TWC filings Right to Sue Letter Medical or psychological records (if relevant) Other Relevant documents Have you suffered financial losses as a result of the conduct? * Yes No Lost wages?In order to be entitled to lost wages, you must be continuing to look for replacement work and to maintain records of your attempts to find replacement workHave you sought mental health care, counseling, or medical treatment due to your employer's conduct? * Yes No If yes, please list out your treating providers along with contact information from whom you have sought medical care the result of your employer's conduct.Please describe how the discriminatory actions have affected you personally and professionally: *Consent(Required) I agree to the privacy policy. Δ *****Disclaimer*****
