Form CIS-U "Complainant Information Sheet (For All Cases Not Related to Housing Discrimination)" - Illinois

What Is Form CIS-U?

This is a legal form that was released by the Illinois Department of Human Rights - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Illinois Department of Human Rights;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CIS-U by clicking the link below or browse more documents and templates provided by the Illinois Department of Human Rights.

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Download Form CIS-U "Complainant Information Sheet (For All Cases Not Related to Housing Discrimination)" - Illinois

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COMPLAINANT INFORMATION SHEET
State of Illinois
(For All Cases not related to Housing Discrimination)
Department of Human Rights
Date:
Office Use Only:
Control No:
Inv. Init.
_______________________
Instructions: Read this entire form and all of the instructions carefully before completing. All questions should be answered, and you may use additional
sheets if necessary. This form must be signed and dated on page 4, and postmarked or received by IDHR within 300 days of the date of the alleged
discrimination. IDHR must establish if it has the right under the law to investigate your claim. If IDHR accepts your claim of discrimination, we will type your
information on an official charge form. The official charge form must be signed, notarized and returned to IDHR in a timely manner.
THIS IS NOT A FORMAL CHARGE. If IDHR accepts your claim, we will send you an official typed charge form for signature.
If your alleged claim of discrimination is related to Housing, such as buying or renting a house or apartment or refused a request to modify your
housing, please STOP and fill out an IDHR Housing Complainant Information Sheet.
1. COMPLAINANT INFORMATION
Name:
Address:
Apt No:
City:
State:
ZIP:
Phone No:
Alt. Phone No:
Alt. Phone No:
E-Mail:
E-Mail Consent: By checking this box, I consent to service of notices by the Department via electronic mail.
Please provide the following information for statistical purposes only.
Country of National Origin:
Sex:
Date of Birth:
2. WHO CAN WE CALL IF WE CANNOT CONTACT YOU
Make sure their mailing addresses are different from your mailing address. Your charge could be
dismissed if you do not provide this information and we are unable to locate you.
Name:
Address:
Apt No:
State:
ZIP:
Phone No:
City:
Address:
Apt No:
Name:
City:
State:
ZIP:
Phone No:
3. RESPONDENT INFORMATION
Write out the full legal name of the company or organization that you believe discriminated against you in Illinois (i.e. the
Respondent). (Employer, Employment Agency, Financial Institution, Union, Place of Public Accommodation, School or University, etc.)
Name:
Address:
Phone No:
State:
ZIP:
City:
Website:
County:
4. WHAT IS YOUR RELATIONSHIP WITH THE RESPONDENT
EMPLOYMENT: Respondent is my Employer / Former Employer / Potential Employer.
NOTE: If the Respondent is an employer, does the Respondent employ:
15 or more employees in the state of Illinois
Yes
No
15 or more employees in the United States
Yes
No
FINANCIAL CREDIT: Respondent is a Financial Institution, such as a bank or an insurance company, to which I applied for an account or line of credit.
PUBLIC ACCOMMODATIONS: Respondent is a Public Entity or Place of Business (of which I am not a current, former, or potential employee), such as a Store,
Restaurant, Public Park, Educational Program, or Public Official, and has denied me a service or access or has subjected me to a form of pervasive harassment.
SEXUAL HARASSMENT IN EDUCATION: Respondent is or represents an Educational Institution in which I (or my minor child) am currently, recently, or I have applied to
be enrolled that I believe has sexually harassed me (or my minor child), or has retaliated against me (or my minor child) for reporting, opposing or for participating in an
investigation of sexual harassment.
What type of business or organization is the Respondent? For example, a Private Employer, Public or Non-Profit Organization,
Office Use Only
State or Local Government, School or University (specify Public or Private, and if it is Elementary, Secondary, Vocational, etc.,
and your current enrollment status), Employment Agency, Municipality, Union, Bank, Insurance Company, Individual, etc.
100 W. Randolph St., 10th Floor, Attn. Intake Unit, Chicago, IL 60601; 312-814-6200; 866-740-3953 (TTY); INTERVIEWS MON.-THURS. 8:30 AM to 3:00 PM
In Springfield: 535 West Jefferson Street, 1st Floor, Attn. Intake Unit, Springfield, IL 62702; 217-785-5100; 866-740-3953 (TTY)
WEBSITE: www.illinois.gov/dhr/
EMAIL: IDHR.Intake@illinois.gov CHICAGO FAX: 312-814-6251 SPRINGFIELD FAX: 217-785-5106
CIS-U. 9/2020
COMPLAINANT INFORMATION SHEET
State of Illinois
(For All Cases not related to Housing Discrimination)
Department of Human Rights
Date:
Office Use Only:
Control No:
Inv. Init.
_______________________
Instructions: Read this entire form and all of the instructions carefully before completing. All questions should be answered, and you may use additional
sheets if necessary. This form must be signed and dated on page 4, and postmarked or received by IDHR within 300 days of the date of the alleged
discrimination. IDHR must establish if it has the right under the law to investigate your claim. If IDHR accepts your claim of discrimination, we will type your
information on an official charge form. The official charge form must be signed, notarized and returned to IDHR in a timely manner.
THIS IS NOT A FORMAL CHARGE. If IDHR accepts your claim, we will send you an official typed charge form for signature.
If your alleged claim of discrimination is related to Housing, such as buying or renting a house or apartment or refused a request to modify your
housing, please STOP and fill out an IDHR Housing Complainant Information Sheet.
1. COMPLAINANT INFORMATION
Name:
Address:
Apt No:
City:
State:
ZIP:
Phone No:
Alt. Phone No:
Alt. Phone No:
E-Mail:
E-Mail Consent: By checking this box, I consent to service of notices by the Department via electronic mail.
Please provide the following information for statistical purposes only.
Country of National Origin:
Sex:
Date of Birth:
2. WHO CAN WE CALL IF WE CANNOT CONTACT YOU
Make sure their mailing addresses are different from your mailing address. Your charge could be
dismissed if you do not provide this information and we are unable to locate you.
Name:
Address:
Apt No:
State:
ZIP:
Phone No:
City:
Address:
Apt No:
Name:
City:
State:
ZIP:
Phone No:
3. RESPONDENT INFORMATION
Write out the full legal name of the company or organization that you believe discriminated against you in Illinois (i.e. the
Respondent). (Employer, Employment Agency, Financial Institution, Union, Place of Public Accommodation, School or University, etc.)
Name:
Address:
Phone No:
State:
ZIP:
City:
Website:
County:
4. WHAT IS YOUR RELATIONSHIP WITH THE RESPONDENT
EMPLOYMENT: Respondent is my Employer / Former Employer / Potential Employer.
NOTE: If the Respondent is an employer, does the Respondent employ:
15 or more employees in the state of Illinois
Yes
No
15 or more employees in the United States
Yes
No
FINANCIAL CREDIT: Respondent is a Financial Institution, such as a bank or an insurance company, to which I applied for an account or line of credit.
PUBLIC ACCOMMODATIONS: Respondent is a Public Entity or Place of Business (of which I am not a current, former, or potential employee), such as a Store,
Restaurant, Public Park, Educational Program, or Public Official, and has denied me a service or access or has subjected me to a form of pervasive harassment.
SEXUAL HARASSMENT IN EDUCATION: Respondent is or represents an Educational Institution in which I (or my minor child) am currently, recently, or I have applied to
be enrolled that I believe has sexually harassed me (or my minor child), or has retaliated against me (or my minor child) for reporting, opposing or for participating in an
investigation of sexual harassment.
What type of business or organization is the Respondent? For example, a Private Employer, Public or Non-Profit Organization,
Office Use Only
State or Local Government, School or University (specify Public or Private, and if it is Elementary, Secondary, Vocational, etc.,
and your current enrollment status), Employment Agency, Municipality, Union, Bank, Insurance Company, Individual, etc.
100 W. Randolph St., 10th Floor, Attn. Intake Unit, Chicago, IL 60601; 312-814-6200; 866-740-3953 (TTY); INTERVIEWS MON.-THURS. 8:30 AM to 3:00 PM
In Springfield: 535 West Jefferson Street, 1st Floor, Attn. Intake Unit, Springfield, IL 62702; 217-785-5100; 866-740-3953 (TTY)
WEBSITE: www.illinois.gov/dhr/
EMAIL: IDHR.Intake@illinois.gov CHICAGO FAX: 312-814-6251 SPRINGFIELD FAX: 217-785-5106
CIS-U. 9/2020
COMPLAINANT INFORMATION SHEET
Illinois Department of Human Rights
5. DESCRIPTION OF THE ISSUES AND BASES YOU ARE REQUESTING IDHR TO INVESTIGATE
Each of your COMPLAINTS of discrimination must be composed of two parts: the ISSUE and the BASIS.
The ISSUE is the harm or action that was taken against you. (Such as being discharged from your place of employment or being denied access to a public service.)
The BASIS is the legally protected class you believe is the reason for the action that was taken against you.
IDHR can only investigate charges alleging specific BASES of discrimination:
Age (+40)
Ancestry
National Origin
Sexual Orientation
Physical Disability or Mental Disability (unrelated to ability to do the job)
Race
Pregnancy
Military Status
Sexual Harassment
Arrest Record (or criminal history record ordered expunged, sealed or impounded),
Aiding and Abetting / Coercion (helping or forcing a person to commit
Sex
Religion
Citizenship Status
Order of Protection Status
discrimination)
Unfavorable Military
Marital Status
Gender Identity
Color (Complexion)
Discharge
Retaliation (complained about unlawful discrimination, filed a prior discrimination claim, or testified at a discrimination hearing)
Your Charge of Discrimination can have multiple COMPLAINTS.
Your BASIS can be the cause of more than one ISSUE, and each ISSUE could have been caused by more than one BASIS.
If your complaint is of SEXUAL HARASSMENT, RETALIATION, AIDING AND ABETTING, or COERCION, your Issue and Basis are the same.
* Unfair Employment, Public Accommodation, or Union Practices ( such as political affiliations, personality conflicts, etc.) unless
IDHR cannot investigate:
such actions are alleged to be for one or more of the Bases listed above * Charges against the federal government or federal officials. * Curriculum content or
course offerings of Educational Programs or Institutions. * Prison Facilities. * Educational institutions regarding discrimination in educational programs other than
sexual harassment.
: Describe the ISSUE or harm. Be specific and concise.
1st COMPLAINT
(Common Issues include: Discharge from place of employment, Retaliation for filing a complaint of
discrimination, Unwelcome sexual advances, Denied access to a public facility, Denied a loan, Creating an intimidating or hostile environment, or Failure to make a reasonable accommodation.)
BASIS: (As described above)
Date(s) of Action:
Name and Job Title of the person who committed the action or gave you this information:
Why do you feel discriminated against because of the basis you have identified, or how has this action created a hostile or offensive environment?
How were others in your situation treated?
: Describe the ISSUE or harm. Be specific and concise.
2nd COMPLAINT
(Common Issues include: Discharge from place of employment, Retaliation for filing a complaint of
discrimination, Unwelcome sexual advances, Denied access to a public facility, Denied a loan, Creating an intimidating or hostile environment, or Failure to make a reasonable accommodation.)
BASIS: (As described above)
Date(s) of Action:
Name and Job Title of the person who committed the action or gave you this information:
Why do you feel discriminated against because of the basis you have identified, or how has this action created a hostile or offensive environment?
How were others in your situation treated?
Please use additional sheets as necessary to provide the above information for each complaint.
CIS-U. 9/2020
COMPLAINANT INFORMATION SHEET
Illinois Department of Human Rights
6. IF YOU HAVE BEEN EMPLOYED BY THE RESPONDENT, PLEASE FILL IN THE FOLLOWING:
Were you on probation?
Yes
No
Job Title:
Hourly
Weekly
Bimonthly
Monthly
Annually
Date Hired:
Salary:
Department:
Supervisor:
7. SPECIAL BASES
7A. If your claim involves SEXUAL HARASSMENT:
Name of the harasser:
Job Title of harasser:
Do you want the sexual harasser charged separately as an additional respondent?
Yes
No
If "Yes", provide contact information for the harasser.
Address:
City:
State:
ZIP:
Phone No:
Describe the action(s) taken against you. Include the date or approximate date of each action. Use additional sheets, if necessary. Common examples include:
Unwelcome sexual advances, Requests for sexual favors, Action contingent upon submission to sexual conduct, or Creating a hostile, or offensive environment.
Was the conduct welcome or unwelcome? If unwelcome, how did you reject the conduct or make it known it was unwelcome?
If your complaint includes an Action contingent upon submission to sexual conduct, were you told what would happen if you did not submit to the sexual advances?
If Yes, what were you specifically told, by whom, and on what date(s)?
7B. If you claimed PHYSICAL DISABILITY or MENTAL DISABILITY as a basis:
State your medically diagnosed disability/disabilities:
Explain how the Respondent became aware of each disability:
7C. If you claimed RETALIATION as a basis:
Name of the retaliator:
Job Title of retaliator:
Do you want the retaliator charged separately as an additional respondent?
Yes
No
If "Yes", provide contact information for the retaliator.
Address:
City:
State:
ZIP:
Phone No:
State how you opposed unlawful discrimination: (i.e., testified at a discrimination hearing, filed a prior discrimination claim, or complained about unlawful
discrimination). Include dates, charge numbers, and/or the name or title of the person to whom you complained.
7D. If your claim involves DENIAL OF FINANCIAL CREDIT:
Explain your understanding of the qualifications necessary to obtain credit from the institution, and how you met those qualifications:
CIS-U. 9/2020
You must sign and date the last page of this form.
COMPLAINANT INFORMATION SHEET
Illinois Department of Human Rights
8. HAVE YOU FILED A GRIEVANCE OR COMPLAINT INTERNALLY WITH THIS RESPONDENT?
(Such as a Human Resources
Department, Manager, Customer Service Center, Union, Advocacy Group, or Guidance Counselor)
If "Yes", to whom did you submit the complaint (name and job title), on what date(s), and what were the results of your complaint thus far?
9. HAVE YOU FILED A PREVIOUS CHARGE AGAINST THIS RESPONDENT WITH IDHR OR ANOTHER INVESTIGATORY
AGENCY OR COMMISSION?
(Such as the EEOC, US Dept. of Education, or the US Dept. of Labor)
Yes
No
If "Yes", when?
Charge Number(s):
10. MEDIATION:
The Department offers mediation as an alternative form of dispute resolution. If both parties agree to participate, mediation may resolve your case
faster. All mediation conferences are held in the Department's Chicago office. If the case is not resolved at Mediation, the case will be investigated.
Yes
No
Are you interested in Mediation?
IDHR Notice of Accessibility
IDHR's programs are accessible to persons with disabilities in compliance with the ADA and Sec. 504 of the Rehabilitation Act of 1973. A person with a
disability needing an accommodation to participate in IDHR programs should contact the ADA Coordinator at 312-814-6262, 312-814-1436 (fax),
866-740-3953 (TTY) or e-mail IDHR.ADA@illinois.gov. IDHR provides interpreters upon request for sign language and for languages other than English.
If a non-English speaking party chooses to secure their own interpreter, the interpreter must be 18 years of age or older and able to communicate
effectively in both languages.
Notice to complainant on release of identity and personal information
The Illinois Human Rights Act (“Act”), 775 ILCS 5/1-101 et seq., and Section 2520.330 of IDHR's Rules and Regulations, 56 Ill. Admin. Code, Ch. II, Section
2520.330, require a charge to contain certain information in such detail as to substantially apprise the parties of the time, place, and facts with respect to the
alleged civil rights violation. Pursuant to the Department's Rules and Regulations (2 Ill. Admin Code, Ch. X, Section 926.210), anyone who submits
information to IDHR in connection with a discrimination charge should take notice and be aware of the following:
(a) All contents and files maintained by IDHR pertaining to charges shall be confidential and not subject to public disclosure. Relevant exceptions are:
(1) the parties to a charge may inspect the file at any time subsequent to the written notice of substantial evidence, default, or dismissal, administrative
closure, or approval of terms of settlement by the Human Rights Commission (“Commission”);
(2) after the filing of a Complaint with the Commission or the institution of judicial proceedings involving a charge, the Director may release
information pertaining to the charge if such information is requested of IDHR or if the Director finds such information newsworthy, useful in education
or training, relevant to an issue before the General Assembly, or similarly appropriate for disclosure.
(b) Authorized personnel within IDHR analyze information that IDHR collects. This information may include personal information. IDHR staff may need to
reveal some of the personal information to individuals outside the office in order to verify facts related to the charge, or to discover new facts which will
help IDHR to determine whether the law has been violated. IDHR may need to disclose to Respondent correspondence that IDHR receives from
Complainant or other sources.
(c) IDHR may release the identity and personal information of the parties pursuant to a Freedom of Information Act (“FOIA”) request, a subpoena or a court
order, and information submitted to or obtained by IDHR may also be revealed to persons outside of IDHR to enforce a Commission Order or a
settlement agreement.
(d) No person is required to file a charge with IDHR and reveal personal information to IDHR; however, if a person files a charge and IDHR cannot obtain
the information needed to fully investigate the allegations in the charge, IDHR may close the case.
CONSENT AGREEMENT AND RELEASE
I have read the provided “Notice to Complainant” and I understand that: 1) If my charge is regarding an employment jurisdiction, IDHR may also file my
charge of discrimination with EEOC if it has jurisdiction, and I authorize EEOC to look into the discrimination alleged above; 2) In the course of investigating
my charge, IDHR will reveal my identity (including my name) and my personal information to named Respondent(s) in my charge to obtain facts and evidence
regarding my charge; 3) I do not have to reveal my personal information to IDHR, but IDHR may close my charge if I refuse to reveal information needed to
fully investigate my charge; 4) IDHR may be required by law, subpoena, court order, and/or FOIA request to disclose my charge and information in the
Department's investigation file concerning my charge to persons outside of IDHR.
If IDHR takes a charge based on the information provided, I consent for IDHR to disclose my identity and personal information as necessary to process and
investigate my charge, and I release IDHR from any liability whatsoever concerning disclosure of my identity and any personal information I provided to IDHR
or IDHR obtained in processing my charge.
My signature below verifies the accuracy of the information provided herein and my consent and release as indicated above.
Print Name
Signature
Date
NOTE: If there is certain personal information you would like withheld, please discuss your concern with an Intake supervisor.
CIS-U. 9/2020
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