Dfeh Complaint Form Blank Sample Pdf Details

If you've been instructed to fill out a Dfeh 300 03 form, you're likely wondering what it is and why you need to complete it. This form is used by the California Department of Fair Employment and Housing (DFEH) to investigate allegations of workplace discrimination. It's important to understand the purpose of this form and how to complete it accurately so that the DFEH can effectively process your claim.

Listed here, you can find quite a few information regarding dfeh 300 03 form PDF. It is really worth making the effort to read this just before you start submitting your document.

QuestionAnswer
Form NameDfeh 300 03 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdfeh complaints, form for responding to dfeh complaint, dfeh complaint form blank sample pdf, dfeh 300 03

Form Preview Example

* * * EMPLOYMENT * * *

COMPLAINT OF DISCRIMINATION UNDER

DFEH #

THE PROVISIONS OF THE CALIFORNIA

 

FAIR EMPLOYMENT AND HOUSING ACT

 

DFEH USE ONLY

CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING

YOUR NAME (indicate Mr. or Ms.)

 

TELEPHONE NUMBER (INCLUDE AREA CODE)

 

 

 

ADDRESS

 

 

 

 

 

CITY/STATE/ZIP

COUNTY

COUNTY CODE

NAMED IS THE EMPLOYER, PERSON, LABOR ORGANIZATION, EMPLOYMENT AGENCY, APPRENTICESHIP COMMITTEE, OR STATE OR LOCAL GOVERNMENT AGENCY WHO DISCRIMINATED AGAINST ME:

NAME

 

 

TELEPHONE NUMBER (Include Area Code)

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

DFEH USE ONLY

 

 

 

 

 

 

 

CITY/STATE/ZIP

 

COUNTY

 

COUNTY CODE

 

 

 

 

 

 

 

NO. OF EMPLOYEES/MEMBERS (if known)

DATE MOST RECENT OR CONTINUING DISCRIMINATION

 

 

RESPONDENT CODE

 

 

 

TOOK PLACE (month, day, and year)

 

 

 

 

THE PARTICULARS ARE:

I allege that on

 

, the

_____ termination

_____ denial of employment

_____ denial of family or medical leave

_____ lay-off

_____ denial of promotion

_____ denial of pregnancy leave

following conduct occurred:

 

 

_____ demotion

_____ denial of transfer

_____ denial of equal pay

 

 

 

 

 

 

_____ harassment

_____ denial of accommodation

_____ denial of right to wear pants

 

 

 

_____ genetic characteristics testing

_____ failure to prevent discrimination or retaliation

_____ denial of pregnancy accommodation

 

 

 

_____ constructive discharge (forced to quit)

_____ retaliation

 

 

 

 

_____ impermissible non-job-related inquiry

_____ other (specify) ____________________________________________

by

because of:

Name of Person

 

Job Title (supervisor/manager/personnel director/etc.)

_____ sex

_____ national origin/ancestry

_____ disability (physical or mental)

_____ retaliation for engaging in protected

_____ age

_____ marital status

_____ medical condition (cancer

activity or requesting a protected

_____ religion

_____ sexual orientation

or genetic characteristic)

leave or accommodation

_____ race/color

_____ association

_____ other (specify) ______________________________________________________

State what you believe to be the reason(s) for discrimination

I wish to pursue this matter in court. I hereby request that the Department of Fair Employment and Housing provide a right-to-sue notice. I understand that if I want a federal notice of right-to-sue, I must visit the U.S. Equal Employment Opportunity Commission (EEOC) to file a complaint within 30 days of receipt of the DFEH "Notice of Case Closure," or within 300 days of the alleged discriminatory act, whichever is earlier.

I have not been coerced into making this request, nor do I make it based on fear of retaliation if I do not do so. I understand it is the Department of Fair Employment and Housing's policy to not process or reopen a complaint once the complaint has been closed on the basis of "Complainant Elected Court Action."

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct of my own knowledge except as to matters stated on my information and belief, and as to those matters I believe it to be true.

Dated

At

City

DATE FILED:

DFEH-300-03 (04/08)

DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING

COMPLAINANT'S SIGNATURE

STATE OF CALIFORNIA

RIGHT-TO-SUE COMPLAINT INFORMATION SHEET

DFEH needs a separate signed complaint for each employer, person, labor organization, employment agency, apprenticeship committee, state or local government agency you wish to file against. If you are filing against both a company and an individual(s), please complete separate complaint forms naming the company or an individual in the appropriate area.

Please complete the following so that DFEH can process your complaint and for DFEH for statistical purposes, and return with your signed complaint(s):

YOUR RACE:/ETHNICITY (Check one)

__ African-American __ African - Other

__ Asian/Pacific Islander (specify)___________

__ Caucasian (Non-Hispanic) __ Native American

__ Hispanic(specify)____________________

YOUR PRIMARY LANGUAGE (specify)

_______________________________________

YOUR AGE: __ __

IF FILING BECAUSE OF YOUR NATIONAL ORIGIN/ANCESTRY, YOUR NATIONAL ORIGIN/ANCESTRY (specify)

_______________________________________

IF FILING BECAUSE OF DISABILITY,

YOUR DISABILITY:

__ AIDS

__ Blood/Circulation

__ Brain/Nerves/Muscles

__ Digestive/Urinary/Reproduction __ Hearing

__ Heart

__ Limbs (Arms/Legs) __ Mental

__ Sight

__ Speech/Respiratory __ Spinal/Back

IF FILING BECAUSE OF MARITAL STATUS,

YOUR MARITAL STATUS: (Check one)

__ Cohabitation __ Divorced __ Married __ Single

IF FILING BECAUSE OF RELIGION,

YOUR RELIGION: (specify)

____________________________________

IF FILING BECAUSE OF SEX, THE REASON: __ Harassment

__ Orientation __ Pregnancy

__ Denied Right to Wear Pants

__ Other Allegations (List) ________________________

DFEH-300-03-1 (04/08)

Department of Fair Employment and Housing

State of California

YOUR GENDER: __ Female __ Male

YOUR OCCUPATION: __ Clerical

__ Craft

__ Equipment Operator __ Laborer

__ Manager

__ Paraprofessional __ Professional __ Sales

__ Service __ Supervisor __ Technician

HOW YOU HEARD ABOUT DFEH: __ Attorney

__ Bus/BART Advertisement __ Community Organization __ EEOC

__ EDD __ Friend

__ Human Relations Commission __ Labor Standards Enforcement __ Local Government Agency __ Poster

__ Prior Contact with DFEH __ Radio

__ Telephone Book __ TV

__ DFEH Web Site

DO YOU HAVE AN ATTORNEY WHO HAS AGREED TO REPRESENT YOU ON YOUR EMPLOYMENT DISCRIMINATION CLAIMS IN COURT? IF YOU CHECK “YES”, YOU WILL BE RESPONSIBLE FOR HAVING YOUR ATTORNEY SERVE THIS DFEH COMPLAINT.

__ Yes

__ No

PLEASE PROVIDE YOUR ATTORNEY’S NAME, ADDRESS AND PHONE NUMBER:

_______________________________________

_______________________________________

_______________________________________

Your Signature

Date

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