Employment Intake Questionnaire--Updated 1/2018

1. You May File A Charge

You have contacted the Kansas Human Rights Commission to seek help concerning possible discrimination in employment. We will ask you questions about what happened to you, about how others were treated, about dates, the size of the employer, and other matters. What you tell us is very IMPORTANT so please be specific in your answers.

First, we will have to establish whether we believe that the law permits us to work on your problem; that is, we must try to find out whether we have JURISDICTION (authority) under the law. If it is clear, based upon what you tell us, that we DO NOT have jurisdiction, we may not be able to accept and investigate your complaint, and we will so inform you.

If you are under 18 years of age, a parent or guardian may file for you.

If you have recently completed this on-line questionnaire and have not yet received your drafted complaint, please contact our Intake Unit at (785) 296-3206 or TDD (785) 296-0245 to inquire about the status. Please do not complete this questionnaire again if you do not have any new allegations or new incidents to report as it delays drafting your complaint.

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* 1. Have you read You May File A Charge?

Yes, I have read You May File A Charge

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* 2. Contact Information

Your Full Legal Name

Address

City

State

Zip

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* 3. Contact Information Continued

Home Phone Number in format of xxx-xxx-xxxx

Cell Phone Number in format of xxx-xxx-xxxx

E-mail Address

Confirm E-Mail Address

Work Phone Number in format of xxx-xxx-xxxx

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* 4. Mr./Ms.

Mr.

Ms.

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* 5. I prefer to be contacted by: (Choose as many as you wish.)

Cell Phone

Home Phone

Personal e-mail

Work Phone

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* 6. I can best be contacted:

Anytime

Other (Please specify day and time i.e. Mondays & Wednesdays, after 9:00 a.m.)

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* 7. Employer Information--Give the full name of the employer that you feel discriminated against you. It is extremely important that the address is accurate. An incorrect address may result in your complaint not being processed. You may be asked to provide verification of the name by either a copy of your pay stub, business card or letterhead.

Company's Full Legal Name *

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 8. Are you now employed by the company, agency, etc.?

Yes

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* 9. Were you employed at a temp agency and placed at this job site?

Yes

If Yes, please list the Full Legal Name of the Temp Agency

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* 10. Date Hired (Skip if not applicable.)

Date

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* 11. Last Date Worked (Skip if currently employed.)

Date

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* 12. Present or Last Job Title (Or Job Title applied for)

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* 13. I was subjected to the following adverse actions due to discrimination/harassment. (Choose as many as applicable.)

I was reprimanded.

I was suspended.

I was terminated.

My work is more closely scrutinized or monitored than others.

I am treated less favorably than others in a similar situation.

I was given worse job duties than others with the same job title.

I was more severely disciplined than others in a similar situation.

I received a worse evaluation than others with similar work performance.

I was laid off.

I was forced to resign or retire.

I quit due to the alleged discrimination/harassment.

I was not hired.

I was not promoted.

I was demoted.

I was denied a pay raise.

I was denied a transfer, i.e. to another department, shift, location, etc.

My disability was not accommodated.

I was not returned to work after an injury or illness.

My religious practices were not accommodated.

I was sexually harassed.

I was harassed due to my race, color, religion, national origin, age (40 years or older), disability, genetic screening or genetic testing.

I am being retaliated against for having previously complained of discrimination/harassment to my employer, or having previously filed a charge with the KHRC or EEOC.

Other (please specify adverse job action)

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* 14. I was harassed by: (Choose as many as applicable.) (Skip this question if it is not applicable.)

I was sexually harassed, either verbally or physically.

I was called names based on my race, color, sex, religion, national origin, age, disability or genetic screening/testing.

I received derogatory remarks due to my race, color, sex, religion, national origin, age, disability, or genetic screening/testing.

I was teased or subjected to "jokes" based on my race, color, sex, religion, national origin, age, disability, or genetic screening/genetic testing.

I received or was subjected to inappropriate images, e-mails, text messages, social media posts, voice mails, phone calls, screen savers, computer images, calendars, posters, etc.

My movements were blocked.

I have been alienated from my co-workers.

Other (please specify)

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* 15. My alleged harasser(s) are: (Check as many as applicable.) (Skip this question if it is not applicable.)

Co-worker(s)

My Supervisor

Another Supervisor

A Member of Management/Owner

Non-Employee/Third Party

Please provide name(s) and title(s )of alleged harassers.