File an Employment Complaint

Page X of X Z questions on this page

Required fields are marked with a red asterisk.

  • If you do not know the answer, type “Unknown”.
  • If the field does not apply to you, type “NA”.
You must complete the entire form to submit it. This form cannot be saved for later.

Disclaimer

You must file an employment discrimination complaint within the time limits imposed by law, generally within 180 days or in some places 300 days of the alleged discrimination. When we get the form, we’ll review it to determine if we can get involved.

  • This form has a total of # questions and # are required.
  • Additional questions can become required based on your answers.

Required Evidence

  • Keep in mind the burden of proof is on you. Your evidence is important and helps determine the outcome of the complaint.

You can download a paper version of the Employment Complaint form if you prefer to fill it out by hand.

Puede descargar una versión impresa del formulario de queja de alojamiento en español.

Check If You Qualify

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Personal Information

Alternate Contact Information

If we cannot reach you directly, who can we contact to help us reach you?

Organization

What organization (e.g. store, restaurant, city government agency) do you believe has discriminated against you?

Check all that apply.

Provide all details for the organization you are filing a complaint against.

Enter this information if the job location and organization address is not the same.

Provide all details for the organization you are filing a complaint against.

Enter this information if the job location and organization address is not the same.

Employment

Discrimination Complaint

What is the reason (basis) for your claim of discrimination? What happened to you that you believe was discriminatory?

Check all that apply.

Provide all details of the event.

Provide all details of the event.

Disability Discrimination

Provide answers for this section if you have a disability or a disability relates to the discrimination claim.

Check all that apply.
For example, what does your disability prevent or limit you from doing, if anything?

Similarly Situated

Use the section below to describe who was in the same or similar situation as you. Don’t compare yourself to a manager, but to a counterpart. How were they treated? For example, who else requested service from the organization? Tell us the reason they said they suffered discrimination, if you know it, and it relates to what you suffered For example, if your complaint is about race, tell us the race of each person.

Provide all details of the person who was in the same situation as you.

Provide all details of the person who was in the same situation as you.

Provide all details of the person who was in the same situation as you.

Witnesses

Tell us about any witnesses, if any, to the discrimination.

Provide all details of the witness.

Provide all details of the witness.

Provide all details of the witness.

Previously Filed Complaints or Assistance

Tell us about any other complaints you’ve filed, whether with us or another agency, or about any assistance you’ve received about this complaint.

Signature and Date

I declare under penalty of perjury, under the State of Louisiana, I certify that all statement contained in this Intake Form and all accompanying documents are true and correct to the best of my knowledge and belief.

By typing your full name in the field above, you are electronically signing the information provided by your responses.
PRIVACY ACT STATEMENT:

This form is covered by the Privacy Act of 1974: Public Law 93-579. Authority for requesting personal data and the uses thereof are:

  1. FORM NUMBER/TITLE/DATE. EEOC/FEPA Intake Questionnaire (10/2006).
  2. AUTHORITY. 42 U.S.C. § 2000e-5(b), 29 U.S.C. § 211, 29 U.S.C. § 626. 42 U.S.C. 12117(a)
  3. PRINCIPAL PURPOSE. The purpose of this questionnaire is to solicit information in an acceptable form consistent with statutory requirements to enable the Commission to act on matters within its jurisdiction. When this form constitutes the only timely written statement of allegations of employment discrimination, the Commission will, consistent with 29 CFR 1601.12(b) and 29 CFR 1626.8(b), consider it to be a sufficient charge of discrimination under the relevant statute(s).
  4. ROUTINE 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 allegations of employment discrimination and to provide such charge filing counseling as is appropriate. Information provided 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. Information may also be disclosed to respondents 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 investigation of a charge of discrimination. It is not mandatory that this form be used to provide the requested information.

Complainant’s Consent for Investigatory Use of Personal Information.

  1. I understand that I am not required to give personal information to the LCHR; however, my complaint may be closed if I refuse to supply information needed to investigate my complaint;
  2. I understand that it is my duty to update the personal information I supply and failure to do so may result in my complaint being closed;
  3. I understand that I may receive a copy of any personal information I submit, if I request it; and
  4. I understand that the information provided by me may have to be released under the Public Records Request.

Based on the foregoing, I hereby give my consent to LCHR to process my complaint.

By typing your full name in the field above, you are electronically signing and acknowledging that you agree to the information above.