Form DHR-21 "Example Discrimination Complaint Form" - Illinois

What Is Form DHR-21?

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 November 1, 2017;
  • 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 printable version of Form DHR-21 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 DHR-21 "Example Discrimination Complaint Form" - Illinois

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EXAMPLE
Discrimination Complaint Form
To: Agency EEO/AA Officer
_________________________________________
Name of Agency
1.
Name__________________________________________________________Telephone__________________________________________
Home Address_____________________________________________________________________________________________________
2.
Are you currently employed by the agency?
Yes_______
No_______
3.
Indicate your present job title, status, work unit, address, telephone number and length of service in your current title:
_______________________________________________________________________________________________________________
Job Title
Status
Unit
________________________________________________________________________________________________________________
Location
Phone Number
Length of Service in Classification
4.
Date of the alleged discriminatory practice: _____________________________________________________________________________
5
.
Basis of the alleged discriminatory practice:
_____Race
_____Color
_____Sex
_____Religion
_____Age
_____Disability
_____National Origin
_____Ancestry
_____Marital Status
_____Military Status
____Pregnancy
_____Retaliation
_____Sexual Orientation
Other__________________________________________
6.
The discrimination occurred in connection with:
_____Interview
_____Hiring Selection
_____Promotion
_____Disciplinary Action
_____Compensation
_____Transfer
_____Lay Off
_____Training Opportunity
_________________
Other (specify)____________________________________________________________
7.
The facts of the alleged discriminatory employment practice are:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
(Continue on additional sheets, if necessary)
8
.
Name(s), Title(s), Work Location(s) and Telephone Number(s) who you believe discriminated against you.
_________________________________________________________________________________________________________________
Name
Title
Location
Phone Number
_________________________________________________________________________________________________________________
Name
Title
Location
Phone Number
9
.
Please supply evidence to document the basis for the discriminatory practice you are claiming, as indicated in your
response to number five of the form.
I have attached supporting evidence:
Yes_____
No_____ If yes, describe attachments:
________________________________________________________________________________________________________________
(Continue on additional sheets, if necessary)
10.
Have you made an effort to resolve the discrimination through your supervisors, the grievance procedure or with any public or private
organization?
Yes_____
No_____
If yes, please explain indicating the outcome of the efforts:
________________________________________________________________________________________________________________
(Continue on additional sheets, if necessary)
COMPLAINT’S SIGNATURE AND DATE FILED
EEO/AA OFFICER’S SIGNATURE AND DATE RECEIVED
DHR 21 (Rev. November 2017)
EXAMPLE
Discrimination Complaint Form
To: Agency EEO/AA Officer
_________________________________________
Name of Agency
1.
Name__________________________________________________________Telephone__________________________________________
Home Address_____________________________________________________________________________________________________
2.
Are you currently employed by the agency?
Yes_______
No_______
3.
Indicate your present job title, status, work unit, address, telephone number and length of service in your current title:
_______________________________________________________________________________________________________________
Job Title
Status
Unit
________________________________________________________________________________________________________________
Location
Phone Number
Length of Service in Classification
4.
Date of the alleged discriminatory practice: _____________________________________________________________________________
5
.
Basis of the alleged discriminatory practice:
_____Race
_____Color
_____Sex
_____Religion
_____Age
_____Disability
_____National Origin
_____Ancestry
_____Marital Status
_____Military Status
____Pregnancy
_____Retaliation
_____Sexual Orientation
Other__________________________________________
6.
The discrimination occurred in connection with:
_____Interview
_____Hiring Selection
_____Promotion
_____Disciplinary Action
_____Compensation
_____Transfer
_____Lay Off
_____Training Opportunity
_________________
Other (specify)____________________________________________________________
7.
The facts of the alleged discriminatory employment practice are:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
(Continue on additional sheets, if necessary)
8
.
Name(s), Title(s), Work Location(s) and Telephone Number(s) who you believe discriminated against you.
_________________________________________________________________________________________________________________
Name
Title
Location
Phone Number
_________________________________________________________________________________________________________________
Name
Title
Location
Phone Number
9
.
Please supply evidence to document the basis for the discriminatory practice you are claiming, as indicated in your
response to number five of the form.
I have attached supporting evidence:
Yes_____
No_____ If yes, describe attachments:
________________________________________________________________________________________________________________
(Continue on additional sheets, if necessary)
10.
Have you made an effort to resolve the discrimination through your supervisors, the grievance procedure or with any public or private
organization?
Yes_____
No_____
If yes, please explain indicating the outcome of the efforts:
________________________________________________________________________________________________________________
(Continue on additional sheets, if necessary)
COMPLAINT’S SIGNATURE AND DATE FILED
EEO/AA OFFICER’S SIGNATURE AND DATE RECEIVED
DHR 21 (Rev. November 2017)