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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Margaret Kraak |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |