Employment Questionnaire

Employment Questionnaire

Complete this employment questionnaire using the extracted questions and fields from the PDF. Preserve the original wording and order as closely as possible.
Identity and Contact Information
Last name
First name
Middle name or initial
Year of birth
Present age
Sex
Racial identity
Hispanic or Latino
Street address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
County
State
Zip code
Daytime telephone
Please enter a valid phone number.Format: (000) 000-0000.
Evening telephone
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Alternate contact person name
Alternate contact person telephone
Please enter a valid phone number.Format: (000) 000-0000.
Employer Information
Employer name
Employer address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer city
Employer state
Employer zip
Employer telephone
Please enter a valid phone number.Format: (000) 000-0000.
Employer email address
example@example.com
Nature of employer’s business
Florida county of employment
Number of employees
Employment Status and History
Currently employed by this employer
Current job title
Date first began working for employer

MonthDayYear
Job title when first began working
If no longer employed – resigned or fired
Last date worked for employer

MonthDayYear
Job title when last worked
If never employed – job applied for
If never employed – date applied

MonthDayYear
Immediate supervisor name
Job duties at time of alleged discriminatory actions
Basis of Discrimination and Related Details
Race
Race (if race claim)
Color
National origin
Sex
Sexual harassment reported to employer
Employer actions based on sexual harassment report
Date employer learned of pregnancy

MonthDayYear
Age (for age claim)
Religion
Requested religious accommodation
Description of religious accommodation request
Employer response to religious accommodation request
Previously filed claim with EEOC or OEO
Previously filed claim through employer’s internal procedures
Testified or assisted someone else in protecting rights
Disability
Requested disability accommodation
Description of disability accommodation request
Employer response to disability accommodation request
Number and ages of dependent children under 18
Marital status
Sexual orientation
Genetic information types involved
How employer obtained genetic information
Incident Details and Supporting Evidence
Date of most recent act of discrimination

MonthDayYear
Brief description of discriminatory action and harm
Employer’s stated reason for treatment
Why you believe the action was discriminatory
Work history, experience, and education
Last performance evaluation and overall performance
Received disciplinary actions
Type and date of any disciplinary actions
Incidents that led to alleged discriminatory treatment
Others committed similar violations
Description of how others were treated differently and identifying information
Company policy or practice applied in discriminatory manner
Witnesses – names, addresses, telephone numbers, and what each knows
Prior Assistance, Complaints, and Submission
Willing to participate in mediation
Sought assistance from another agency or attorney
Name of source of assistance
Date of assistance

MonthDayYear
Results of assistance
Previously filed complaint with OEO or EEOC
Date complaint filed with OEO or EEOC

MonthDayYear
Charge or complaint number
Continuation sheet – additional information
Signature
Printed name
Date signed

MonthDayYear
Should be Empty:

Employment Questionnaire

Identity and Contact Information

Employer Information

Employment Status and History

Basis of Discrimination and Related Details

Incident Details and Supporting Evidence

Prior Assistance, Complaints, and Submission