cc-4, revised 1/20 Complaint Involving Employment Discrimination by a Feder

Complaint Involving Employment Discrimination by a Federal Contractor or Subcontractor

Please read the instructions before completing this form.

• Race

• American Indian or Alaska Native

Indicate Tribal Affiliation:

_____________________

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Protected Veteran Status

(See instructions for definitions) Note: You will be asked to provide a DD Form 214.

• Disability

Company

Name: ____________________________________________________________________

Street Address: _____________________________________________________________

City, State, Zip Code: _________________________________________________________

Telephone Number: __________________________________

Give the date(s) and times you believe you were discriminated against:

________________________________________________________________

What company or employer do you believe discriminated against you?

OMB: 1250-0002

Expires: XX/XX/XXXX

How can we reach you?

Name (First, Middle, Last): ____________________________________________________

Street Address: _____________________________________________________________

City, State, Zip Code: _________________________________________________________

Telephone Number: __________________ ____ Home ____ Work ____ Cell

Email: ___________________________________

Have you filed these allegations of employment discrimination with another federal or local agency? _________ Yes _________ No

If yes, which agency: _________________________________________________

Contact Name: ____________________ Phone Number: _________________

Name (First, Middle, Last): ____________________________________________________

Street Address: _____________________________________________________________

City, State, Zip Code: _________________________________________________________

Telephone Number: __________________ ____ Home ____ Work ____ Cell

Email: __________________________________________________________

Who can we contact if we cannot reach you?

• National Origin

• Hispanic or Latino

• Other

• Color

• Religion

• Sex/Gender

• Pregnancy

• Retaliation

• Filing a complaint

• Other

Why do you believe this company or employer discriminated against you?

Where did you learn you could file a complaint with OFCCP?

Internet Poster Community Organization OFCCP Meeting/Event Brochure Other

Form CC-4 (revised 01/2014)

Signature and Verification

I declare under penalty of perjury that the information given above is true and correct to the best of my knowledge or belief. A willful false statement is punishable by law.

I hereby authorize the release of any medical information needed for this investigation.

Signature of Complainant: __________________________ Date: ______________________

Do you believe other employees or applicants were treated the same way as you described above? _________ Yes _________ No

Do you believe there were other employees or applicants who received better treatment than you did because of their race, sex, color, religion, or national origin? _________ Yes _________ No

Do you think the discrimination includes or affects others?

If you are represented by an attorney, or another person, or an organization, please provide their contact information below.

Name (First, Middle, Last): ____________________________________________________

Street Address: _____________________________________________________________

City, State, Zip Code: _________________________________________________________

Telephone Number: __________________ Email: _____________________________

Who should we contact if we need more information about your description of what occurred? ____ You ____Your Representative

Do you have an attorney or other representative?

Your Complaint:

Please describe below what you believe the employer did or didn’t do that you believe caused discrimination or retaliation.

Provide the information below and describe in detail what happened:

-Why you believe the act(s) were (1) discriminatory based on your race, sex, color, religion, national origin, disability, veteran status; and/or (2) retaliation for filing a complaint, participating in discrimination proceedings or otherwise opposing discrimination under any of the above listed bases;

-When did it happen, where and who was involved;

-What harm, if any, was caused to you or others with whom you work as a result of the alleged discriminatory or retaliatory act(s);

-What explanation, if any, was offered for the act(s) by the employer or their representatives; and

-What information do you have on federal contracts held by the company.

Please attach additional pages, if needed.

1