CC-4 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

• Disability

• Retaliation

Company

Name: ____________________________________________________________________

Street Address: _____________________________________________________________

City: _________________________________ State: _______ Zip Code: ___________

Telephone Number: __________________________________

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

________________________________________________________________

What is the name of the employer that you believe discriminated or retaliated against you?

OMB: 1250-0002

Expires: XXXX

Submit

Reset Form

Print Form

How can we reach you?

Name (First, Middle, Last): ____________________________________________________

Street Address: _____________________________________________________________

City: _________________________________ State: _______ Zip Code: ___________

Telephone Number: __________________ ____ Home ____ Work ____ Cell

E-mail: ___________________________________

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

E-mail: __________________________________________________________

Who can we contact if we cannot reach you?

• Sexual Orientation

• Gender Identity

• Inquiring About Pay

• Discussing Pay

• Disclosing Pay

• National Origin

• Hispanic or Latino

• Other

• Color

• Religion

• Sex

Why do you believe your employer discriminated or retaliated against you?

How did you learn that you could file a complaint with OFCCP?

Internet Poster Community Organization OFCCP Meeting/Event Brochure Other

Form CC-4 (revised 01/20XX)

Form CC-4 (Revised 01/20XX)

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

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 think the discrimination includes or affects others?

Do you have an attorney or other representative?

Your Complaint:

Please describe below what you think the employer did or didn’t do that you believe caused discrimination or retaliation, including:

- What actions the employer took against you.

- Why you believe those actions were based on your: race; color; religion; sex; sexual orientation; gender identity; national origin; disability; veteran status; and/or inquiries about, discussions, or disclosures of your pay or the pay of others; and/or in retaliation for filing a complaint, participating in discrimination proceedings, opposing unlawful discrimination, or exercising any other rights protected by OFCCP.

-When the employer actions happened, where they happened, and who was involved.

-What harm, if any, you or others suffered because of the alleged discrimination or retaliation.

-What explanation, if any, your employer or people representing your employer offered for their actions.

- Who was in the same or similar situation as you and how they were treated. Include information such as the race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected status of these individuals, if known.

-What information you have about federal contracts the company that you worked for had at the time of the discrimination or retaliation you describe in this complaint.

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