Filling out the EEOC Form 283, also known as the Intake Questionnaire, is a critical step for individuals who believe they have faced discrimination in the workplace. Protected under the Privacy Act of 1974, this form requires candid responses from the complainant regarding the nature of the alleged discrimination, including details such as the name of the person filling out the form, contact information, and specific allegations of discrimination based on race, sex, religion, national origin, age, retaliation, color, or other specified reasons. It asks individuals to clearly outline the discriminatory actions taken against them, any harm suffered as a result, and whether these actions were believed to be because of any protected attributes. Additionally, the form inquires about the involvement of the employer, union, or employment agency in the discrimination, the employment details of the aggrieved party, consent for identity disclosure, and past efforts to seek assistance or file charges with the EEOC or other entities. Designed to help the Commission assess jurisdiction and the relevance of complaints, the intake process is voluntary yet pivotal for the accurate and efficient processing of discrimination charges. Information provided can be used by the EEOC to determine the legitimacy of claims and may be shared with relevant state, local, and federal agencies as necessary, highlighting the form's significance in the fight against workplace discrimination.
| Question | Answer |
|---|---|
| Form Name | Eeoc Form 283 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | form 50 283, osdh fillable form 283, form 283, fillable form 283 |
INTAKE QUESTIONNAIRE
This form is affected by the Privacy Act of 1974; see Privacy Act Statement on page 2 before completing this form
EEOC USE ONLY Name (Intake Officer)
Please answer the following questions, telling us briefly why you have been discriminated against in employment. An officer of the EEOC will talk with you after you complete this form.
(Please Print)
NAME: __________________________________________________________________________________________________________ DATE: ________________
(First)(Middle name or initial)(Last)
ADDRESS____________________________________________________________ TELEPHONE: ______________________________________________________
CITY: ______________________________________ STATE: _________________________ ZIP CODE: ______________________ COUNTY: ________________
What action was taken against you that you believe to be discriminatory? What harm, if any, was caused to you or others in your work situation as a result of that action? (If more space is required, use page 2.)
Do you believe this action was taken against you because of: (Check the one(s) that apply and specify your race, sex, age, religion or ethnic identity.)
□RACE □ SEX □ RELIGION □ NATIONAL ORIGIN □ AGE □ RETALIATION □ COLOR
□OTHER, EXPLAIN BRIEFLY: _________________________________________________________________________________
I WAS DISCRIMINATED AGAINST BY: (Check the one(s) that apply.) |
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□ EMPLOYER |
□ UNION |
□ EMPLOYMENT AGENCY □ OTHER (Specify) _____________________________ |
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NAME: __________________________________________________________________________ |
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NAME: __________________________________________________________________ |
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ADDRESS: _______________________________________________________________________ |
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ADDRESS: _______________________________________________________________ |
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CITY, STATE, ZIP CODE: __________________________________________________________ |
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CITY, STATE, ZIP CODE: __________________________________________________ |
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APPROXIMATE NUMBER EMPLOYED BY THIS EMPLOYER |
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WHAT WAS THE MOST RECENT DATE THE HARM YOU ALLEGED |
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TOOK PLACE? |
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Are you now employed by the Employer that harmed you? Answer below.
Yes: From _________________________No: I Applied for _________________________ or: I was employed as: ________________
(Date)(Position)(Position)
Current Position: _______________________________ on__________________________ until I was: _______________________
Normally, your identity will be disclosed to the organization which allegedly discriminated against you. Do you:
□CONSENT, or □ NOT CONSENT to such disclosure?
Have you sought assistance about the action you think was discriminatory from any Government agency, from your union, an attorney, or from any other source?
□No □ Yes (If answer is yes, complete below.)
NAME OF SOURCE OF ASSISTANCE: __________________________________________________DATE: ____________________
RESULT, IF ANY:
Have you filed an EEOC Charge in the past?□ No□ Yes (If answer is yes, complete below.)
Approximate date filed: ____________Organization charged: __________________________Charge Number (if known): ___________
SIGNATURE: ____________________________________________________________________________________
DATE: _________________________________________________
EEOC Form 283
PRIVACY ACT STATEMENT
(This form is covered by the Privacy Act of 1974; Public Law
1. FORM NUMBER / TITLE / DATE. EEOC Form 283, Intake Questionnaire, March 1984
2. AUTHORITY. 42 U.S.C.
3.PRINCIPAL PURPOSE (S). The purpose of this questionnaire is to solicit information to enable the Commission to avoid the intake of matters not within its jurisdiction.
4.ROUTING USES. Information provided on this form will be used by Commission employees to determine the existence of facts relevant to a decision as to whether the Commission has jurisdiction over potential charges,
complaints or allegations of employment discrimination and to provide on this form may be disclosed to other
State, local and federal agencies as may be appropriate or necessary to carrying out the Commission’s functions.
This would include employment practices 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 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 processing of a charge of discrimination. It is not mandatory that this form be used to provide the requested information.
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