Form CC-390 Pre-Complaint Inquiry for Employment Discrimination Invo

Pre-Complaint Inquiry for Employment Discrimination Involving a Federal Contractor or Subcontractor

OMB: 1250-0002 Read the instructions below before completing this form.

Expires: X/XX/XXXX Submitting this form to OFCCP is not the same as filing a complaint.

Instructions

It is illegal for companies doing business with the Federal Government to discriminate against you based on your race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or because you asked about, disclosed, or discussed your pay or, in certain instances, the pay of other applicants or employees. Additionally, it is illegal for these companies to retaliate or otherwise take negative employment action against you because you filed a pre-complaint inquiry or complaint, opposed acts or practices made unlawful by OFCCP's authorities, or assisted or participated in a compliance evaluation or complaint investigation.

You can contact OFCCP if you think you have been discriminated against in employment, or in applying for employment, by a company doing business with the Federal Government because of your race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or for asking about, discussing, or disclosing your compensation or that of others. You can also contact OFCCP if you believe the employer retaliated or otherwise took negative employment action against you because you filed a pre-complaint inquiry or complaint, opposed acts or practices made unlawful by OFCCP's authorities, or assisted or participated in a compliance evaluation or complaint investigation, or if you think a company doing business with the Federal Government is in violation of other OFCCP contractor obligations. You do not need to know with certainty that the employer is a federal contractor or subcontractor to contact OFCCP or to submit a pre-complaint inquiry. OFCCP can provide information about your workplace rights and protections to inform your decision on whether to file a complaint with OFCCP.

So that OFCCP can assist you, please complete the information below. OFCCP will review your inquiry to determine whether OFCCP is the right federal agency to handle the matter. If you have questions or need assistance, contact the OFCCP Help Desk at 1-800-397-6251.

Important Deadlines

Submitting this inquiry form to OFCCP does not constitute filing a complaint. If you do not file a complaint of discrimination within the time limits noted below, you will lose your rights to proceed through OFCCP. Submitting this inquiry form does not extend the period for filing a complaint. If you have 60 days or fewer in which to file a timely complaint, visit OFCCP’s website for special instructions (INSERT WEB ADDRESS).

Complaints based on your race, color, religion, sex, sexual orientation, gender identity, or national origin must be filed with OFCCP within 180 days of the action(s) taken by the employer that you think was either discrimination or retaliation.

Complaints alleging discrimination for discussing, disclosing, or inquiring about pay must be filed with OFCCP within 180 days of the action(s) taken by the employer that you think was either discrimination or retaliation.

Complaints based on your disability or status as a protected veteran must be filed with OFCCP within 300 days of the action(s) taken by the employer that you think was either discrimination or retaliation.

How and where do I submit a pre-complaint inquiry?

To submit a pre-complaint inquiry, complete all sections on this form. If you do not know the answer to a question, write “not known.” If a question is not applicable, write “N/A.”

If you are submitting online, fill out the fields and click Submit. If you are not submitting online, send the completed form to OFCCP by mail, fax, or e-mail. Send the form to the OFCCP regional office that covers the state where the events occurred. You may also complete the form in person at an OFCCP office. A list of regional offices and the states that each office covers can be found on the OFCCP website: (http://www.dol.gov/ofccp/contacts/regkeyp.htm).

How can we reach you?

Name (First, Middle, Last): ____________________________________________________

Street Address: _____________________________________________________________

City: _________________________________ State: _______ Zip Code: ___________

Telephone Number: __________________ E-mail: ___________________________________

Who can we contact if we cannot reach you?

Name (First, Middle, Last): ____________________________________________________

Street Address: _____________________________________________________________

City: _________________________________ State: _______ Zip Code: ___________

Telephone Number: __________________ E-mail: ___________________________________

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

Name (First, Middle, Last): ____________________________________________________

Street Address: _____________________________________________________________

City: _________________________________ State: _______ Zip Code: ___________

Telephone Number: __________________ E-mail: _____________________________

Give the most recent date you believe you were discriminated or retaliated against.

Date: __________________________________

Do you think the discrimination includes or affects others?

☐ Yes ☐ No ☐ I’m not sure

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

Employer Name: ____________________________________________________________________

Street Address: _____________________________________________________________

City: _________________________________ State: _______ Zip Code: ___________

Telephone Number: __________________________________

Is this the same location where the discrimination occurred? _______ Yes _______ No

If no, where did the discrimination occur? ____________________________________________________

On what basis do you believe the employer discriminated against you?

Check all that apply:

☐ Race

☐ National Origin

☐ Color

☐ Religion

☐ Sex (including pregnancy)

☐ Sexual Orientation

☐ Gender Identity

☐ Protected Veteran Status

☐ Disability

☐ Discussing Pay

☐ Inquiring About Pay

☐ Disclosing Pay

☐ Other: _________________

☐ Retaliation

o Filing a discrimination complaint

o Contacting a government agency to complain about discrimination

o Complaining to the employer about discrimination

o Participating in OFCCP investigation

o Participating in someone else’s complaint about job discrimination

o Other: _________________

What employment practice do you believe was discriminatory?

☐ Discharge, firing, or lay-off

☐ Harassment (including unwelcome verbal or physical conduct)

☐ Hiring or promotion

☐ Assignment

☐ Pay (unequal wages or compensation)

☐ Failure to provide reasonable accommodation for a disability or a sincerely held religious belief, observance, or practice

☐ Benefits

☐ Job training

☐ Classification

☐ Referral

☐ Requesting or disclosing medical information of employees

☐ Conduct that might reasonably discourage someone from opposing discrimination, filing a charge, or participating in an investigation or proceeding

☐ Other: _________________

Have you filed this allegation of employment discrimination with another federal or local agency (e.g., Equal Employment Opportunity Commission or state or local Fair Employment or Human Rights Commission)?

☐ Yes ☐ No ☐ I’m not sure

If yes, which agency? _______________________________ When did you file? ___________________________

Agency Contact Name: ______________________________ Phone Number: ___________________________

E-mail: ___________________________________________ Case Number (if known): ________________________

How did you learn that you could ask OFCCP for help?

☐ Internet ☐ Poster ☐ Community Organization ☐ OFCCP Meeting/Event ☐ Brochure ☐ Other: __________

Privacy Act Statement

The collection of information using this form is authorized by the legal authorities OFCCP enforces as well as by Title VII of the Civil Rights Act of 1964 (Title VII), as amended, and Title I of the Americans with Disabilities Act of 1990 (ADA), as amended, which the U.S. Equal Employment Opportunity Commission (EEOC) enforces. OFCCP uses this information to assist you in determining whether OFCCP is the appropriate agency to investigate your complaint. Providing this information to OFCCP is not the same as filing a complaint. If you do not file a complaint of discrimination within the time limits described above, you will lose your rights to proceed through OFCCP. The information collected may be disclosed to other agencies that may have jurisdiction over your allegations such as the EEOC.

Providing this information is voluntary; however, failure to provide the information may delay or prevent OFCCP from helping you file your complaint.

Public Burden Statement

The estimated time to complete this form is 15 minutes, including time for reviewing instructions, filling out the form and sending it to OFCCP. Please note that you are not required to respond to this collection of information unless it displays a currently valid OMB Control Number.

If you have comments regarding the estimated burden or any other aspect of this pre-complaint inquiry form, including suggestions for reducing the burden, send them to the OFCCP Policy Division (1250-0002), 200 Constitution Avenue, N.W., Room C3325, Washington, D.C. 20210. Please do not send the completed pre-complaint inquiry form to this address.

THIS PRE-COMPLAINT INQUIRY IS NOT A COMPLAINT OF DISCRIMINATION

4 Form CC-390