Form Mchr 44 – Fill Out and Use This PDF

	MISSOURI DEPARTMENT OF LABOR
	AND INDUSTRIAL RELATIONS	3315 West Truman Blvd.
	INTAKE QUESTIONNAIRE	Room 212
		P.O. Box 1129
	Employment Complaints
		Jefferson City, MO 65102-1129

(Not an Official Complaint Form)

Immediately complete this form and return it to the Missouri Commission on Human Rights (MCHR). REMEMBER, a complaint of discrimination must be filed within the time limits imposed by law, within 180 days of the alleged act of discrimination. Upon receipt, this form will be reviewed to determine MCHR coverage. ANSWER ALL QUESTIONS that pertain to your situation, as completely as possible, and

attach additional pages if needed to complete your response(s). If you do not know the answer to a question, answer by stating “not known.” If a question is not applicable to your situation, write “n/a.”

Please print.

PERSONAL INFORMATION

Last Name	First Name					Middle Initial
Address						Apt. or Unit Number
City		County			State			ZIP
Home Phone Number				Work Phone Number
Cell Phone Number				E-mail Address
Date of Birth		Sex				Do you have a disability?
		Male	Female			Yes	No

Provide the name of a person we can contact if we are unable to reach you.

Answer the next 2 questions.

1.Are you Hispanic or Latino? Yes No

2.What is your race? (Choose all that apply.)

American Indian or Alaskan Native	Asian
Black or African-American	White
Native Hawaiian or Other Pacific Islander	Other (Specify):

3.What is your National Origin? (country of origin or ancestry)

COMPLAINT INFORMATION

4. I believe that I was discriminated against by the following organization(s): (Check those that apply)

Employer Union Employment Agency

Other (Specify):

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. Organization Contact Information

Organization #1 Name
Address				County
City		State		ZIP
Phone Number				Type of Business
Number of Employees in the Organization at All Locations (Check one)
0-5	6-15	15+
Are there employees of the organization in other states?			Yes	No
Organization #2 Name
Address				County
City		State		ZIP
Phone Number				Type of Business
Number of Employees in the Organization at All Locations (Check one)
0-5	6-15	15+
Are there employees of the organization in other states?			Yes	No

6.What is the reason (basis) for your claim of employment discrimination?

FOR EXAMPLE, if you feel that you were treated worse than someone else because of race, you should check the box next to Race. If you feel you were treated worse for several reasons, such as your sex, religion, and national origin, you should check

all that apply. If you complained about discrimination, participated in someone else's complaint, or filed a charge of discrimination, and a negative action was threatened or taken, you should check the box next to Retaliation.

Race/Color Sex Age Disability National Origin Religion Pregnancy Sexual Harassment

Other reason (basis) for discrimination (Explain):

Retaliation – Activities that are protected from retaliation under the Missouri Human Rights Act are:

a.Filing a discrimination complaint, testifying, assisting, or participating in any manner in any investigation, proceeding, or hearing regarding a discrimination complaint; and/or

b.Opposing any practice prohibited by the Missouri Human Rights Act.

7.Background on the alleged discrimination. Which of the following employment action(s) were taken against you?

(Check only those that apply.)

Fired	Harassed	Denied Benefits (Leave, Insurance, etc.)
Not Hired	Disciplined	Denied Pay Raise
Not Promoted	Suspended	Denied Religious Accommodation
Demoted	Laid Off	Denied Disability Accommodation
Transferred	Not Recalled from Layoff	Other:

8.Explain what happened to you below and include the date(s) of harm, action(s) and the name(s) and title(s) of the persons who you believe discriminated against you.

(Example: 10/02/06 – Written Warning from Supervisor, Mr. John Soto)

A. Date

Action

Name of Person(s) Responsible

Title of Person(s) Responsible

B.

Date

Action

Name of Person(s) Responsible

Title of Person(s) Responsible

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Describe any other actions you believe were discriminatory. (Attach additional pages, if needed to complete your response.)

What reason(s) were given to you for the acts you consider discriminatory? By whom? Title?

9.Name and describe others who were in the same situation as you. Explain how they were treated. Who was treated better, and who was treated the same? Provide race, sex, age, national origin, religion, and/or disability status of all such other persons if known and if relevant to your claim of discrimination. (Add additional sheets, if needed.)

10. Have you previously filed a charge in this matter with EEOC or another agency?	Yes	No
If “Yes,” provide name of the agency and date of filing.

11.If you are claiming discrimination based on disability, answer the following questions. If not, proceed to end to sign and date questionnaire. (Check all that apply.)

Yes, I have an actual disability

I have had an actual disability in the past

No disability but the organization treats me as if I am disabled

If you are alleging discrimination because of your disability, what is your disability? How does your disability affect your daily life or work activities, e.g., what does your disability prevent or limit you from doing, if anything? (Example: lifting, sleeping normally,

breathing normally, pulling, walking, climbing, caring for yourself, working, seeing, hearing, bending, talking, standing, thinking, relating to others, etc.).

Did you ask your employer for any assistance or change in working conditions because of your disability?

Yes No

Describe the assistance or change in working conditions requested?

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