Please read these instructions BEFORE you begin answering the questions on the complaint form.
If possible, TYPE your answers. If typing is not possible, then print your answers in INK. Do not write in longhand. Use black ink, and no pencil.
Q. #1 First Name, Middle Initial, and Last Name
example: Mary J. Doe
Q. #2 Home Address
Q. #3 Home Telephone Number
Q. #4 National Origin is your birth Country or ancestry. (It
is not necessary to give us City and State where born.)
Q. #5 Basis is the personal characteristic which accounted
for the alleged discrimination.
Q. #6 Area is where the alleged discrimination occurred.
Q. #7 Full legal name and address of the business or company that is responsible for the alleged discrimination.
example: Queen Burgers, Inc.
Q. #8 What does the company make? Or what service does the
Q. #9 Full legal name, address, and telephone number of the
"parent" company or corporate office
Q. #10 Estimate the total number of employees at all locations.
Q. #11 Did you file a complaint alleging discrimination with
another anti-discrimination agency regarding these same set of
facts before you contacted the Iowa Civil Rights Commission? If
so, what agency and when?
Q. #12 The Equal Employment Opportunity Commission (EEOC) is
a federal agency that enforces federal employment anti-discrimination
laws. If your complaint can be cross-filed with the EEOC, it will
be cross-filed automatically unless you protest and tell us in
writing: "Don't cross-file." Cross-filing preserves
your rights under federal anti-discrimination law.
Q. #13 Legal name and job position of person who discriminated against you
example: Bill A. Jones, District Manager
Q. #14 Legal name and job position of person who harassed you
example: Susan K. Smith, Supervisor. Use her name in
the narrative and give examples of the harassment.
Q. #15 The last date something negative happened to you usually
triggers the filing limitations period. Complaints must be filed
with the Iowa Civil Rights Commission within 180 days of that
Include what happened on that date.
example: not hired or terminated or last time harassed
Please first write your narrative on a separate sheet of paper and then work on it until you are satisfied. Then transfer it to the complaint form. Keep your narrative as brief as possible. Use only the space provided on page.
In your narrative, be sure to provide the following information:
1. What happened?
2. When did it happen?
3. Who made the decision for the company?
4. What makes you think the decision or action was discriminatory?
5. Why do you believe that your race, age, sex, etc. was a
factor in the company's decision?
A. I was terminated by Mark B. Jones, my supervisor, on May
15, 1998. I believe I was fired because of my age. I am 67 years
old. Younger co-workers who had less experience and inferior work
records were retained.
B. Since my date of hire, June 12, 1996, I have been harassed
by Jim Smith, a supervisor, because of my race. He calls me names
and criticizes my work constantly. He treats me very differently
from my white co-workers. I am African American. I believe he
is treating me differently because of my race.
C. On June 15, 1998, I applied for a sales position at the
company's downtown location. I was qualified for the position.
I had 10 years of experience. A male with no experience was selected
over me. I am female. The company has approximately 35 sales persons.
Only 5 are female. I believe my sex was a factor in the company's
decision not to hire me.
D. On May 28, 1998, I learned that I was being paid less than
my male co-workers. I started working at the company on June 1,
1997. I make $7.00 per hour. My male co-workers make $7.50 per
hour. We all do the same job. We have the same duties. I am female.
I believe that I am being paid less because of my sex.