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City of Corpus Christi


EMPLOYMENT INTAKE QUESTIONNAIRE


A charge must be filed with EEOC within 300 days from the date of the alleged violation, in order to protect
the charging party's rights. If you are close to the 300th day since the alleged violation, please
call our office immediately at (361) 826-3190 to preserve your rights to file.

(If you file a Claim of Discrimination, your identity will be disclosed to the alleged violator)


 


Personal Information
Name:
Phone # :
Date of Birth:
Complete Address:
                                (No. & Street, City, State, Zip Code)

Contact Information (An individual who will know how to contact you at all times.)
Name: Phone # :
Complete Address:
                                (No. & Street, City, State, Zip Code)

Basis(es) for Discrimination
I believe that I have been Discriminated against based on one or more of the following:
  (check all that apply & identify)
Race:
Religion:
Sex: Male / Female Pregnancy
Retaliation *
National Origin:
Disability:
Age:
Color:
  (* for protesting a prohibited employment practice or filing a previous charge of discrimination)

I believe I was discriminated against by:
  (check only one box)
Employer Employment Agency
Prospective Employer Union - Local No.

Most Recent Date of Alleged Violation:
(Violation must have occurred within 300 days before today's date.)

Name:
Phone # :
Complete Address:
                                (No. & Street, City, State, Zip Code)

Approximate # of Employees:
(Company must have a minimum of 15 employees.)

Date of Hire:
Date of Application:
Current/Last Position Held :
Position Applied for :

Are you currently employed by the above-named employer?    Yes    No
If No, last date of Employment: Resigned Laid-Off Terminated

Immediate Supervisor's Name: Title:

Additional Information
Have you filed a Claim of Discrimination in the past?   Yes   No
Approximate Date Filed: Employer Filed Against:
Claim # :

Briefly describe what action was taken against you that caused you to believe that you were discriminated against. Include date(s) [month/year] and name and title of the individual(s) taking action.
Witnesses [Include their home telephone # and/or address.]

Comparable(s)[Individual(s) who have committed the same violations; however, action was either less severe or not taken against them.]
What solution are you seeking to resolve your complaint?

PRIVACY ACT STATEMENT
(This form is covered by the Privacy Act of 1974; Public Law 93-579. Authorities for requesting the personal data and the uses thereof are given below.)
  1. FORM NUMBER / TITLE / DATE. CCHRC Form 1, Intake Questionnaire, December 1999.
  2. AUTHORITY. City of Corpus Christi Ordinance No. 023411, as amended, Chapter 24, Article IV; Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000e-4; and/or the Americans with Disabilities Act of 1990, 42 U.S.C. 12101 et seq.
  3. PRINCIPAL PURPOSE. The purpose of this questionnaire is to solicit information to enable the Commission to avoid the intake of matters not within its jurisdiction.
  4. ROUTINE USES.Information provided on this form will be used by Commission employees to determine the evidence of facts relevant to a decision as to whether the Commission has jurisdiction over potential charges, complaints or allegations of employment discrimination. Information provided on this form may be disclosed to other state, local, and federal agencies as may be appropriate or necessary in carrying out the Commissioners' functions, including employment practice laws. Information may also be disclosed to charging parties in consideration of, or in connection with litigation.
  5. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND THE EFFECT ON INDIVIDUAL FOR NOT PROVIDING INFORMATION. The providing of this information is voluntary but the failure to do so may hamper the Commission’s investigation of a charge of discrimination. It is not mandatory that this form be used to provide the requested information.

Pressing the submit button will send the information entered to the Corpus Christi Human Relations Commission. Please verify that all the above information is correct before submitting. There will be no preview page.
If you are not contacted in 7 days, please call (361) 826-3190