Form MODOL-4519 "Equal Opportunity Complaint Form" - Missouri

What Is Form MODOL-4519?

This is a legal form that was released by the Missouri Department of Labor and Industrial Relations - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2020;
  • The latest edition provided by the Missouri Department of Labor and Industrial Relations;
  • 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 MODOL-4519 by clicking the link below or browse more documents and templates provided by the Missouri Department of Labor and Industrial Relations.

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Download Form MODOL-4519 "Equal Opportunity Complaint Form" - Missouri

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For Labor O ffice Use Only
EQUAL OPPORTUNITY
DCIF Re ce ive d
Jurisdiction
COMPLAINT FORM
By: _____________
Yes
No
Date : ____________
Case # ____________
This form is to be used for complaints against the Missouri Department of Labor and Industrial Relations (DOLIR) or its employees in
the provision of services to the public or for complaints by DOLIR employees concerning DOLIR administration, supervisors, or other
employees.
This form is not to be used for filing complaints with the Missouri Commission on Human Rights (MCHR) under the Missouri Human
Rights Act (MHRA). For information regarding MCHR and MHRA, visit labor.mo.gov/discrimination.
COMPLAINT INFORMATION
(Please print)
First Name
Last Name
Social Security Number (Voluntary)
Address
Home Phone (Include Area Code)
Other Phone (Include Area Code)
City
State
Zip Code
Email Address
What is the most convenient time and place for us to contact you about this complaint?
a.m.
p.m.
To the best of your recollection on what date(s) did the
Date of First Occurrence
Date of Most Recent Occurrence
discrimination take place?
Basis of Complaint: Which of the following best describes why you believe you were discriminated against. (Check ALL that apply.)
Race
Religion
Reprisal/Retaliation
Political
Color
Disability
National Origin
Citizenship
Age: Date of Birth:
Other:
Sex:
Male
Female
Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved.
Be sure to include how other persons were treated differently from you. Also attach any written material pertaining to your case.
(Attach separate sheet if needed.)
Do you think the discrimination against you involved: (Check one)
Your previous employer?
OR
A Labor Department employee providing/not providing you with services or benefits?
If so, which of the following are involved?
Appeal – Tax
Overpaid Benefits
Appeal – Tax Intercept
Reporting Requirements
Appeal – Lottery Intercept
Request for Confidential Information
Benefit Payments
Request to Reconsider a Denial of Benefits
Collecting Overpaid Benefits
Questions Regarding TAA/TRA
Collections
Questions Regarding Self-employment/Employment
Contributions Field Auditors
Verification of Social Security Number
Filing a New/Renewed/Weekly Claim
Wage Adjustments in Base Period of Claims
Investigation/Adjudication of a Work Separation or Job Refusal
Waiver of Work Search Requirement if Recall Date
Investigation/Adjudication on Able/Available/Schooling
Other: _____________________________________
Other Investigations/Adjudication
_____________________________________
MODOL-4519 (03-20) AI
H.Rel.
For Labor O ffice Use Only
EQUAL OPPORTUNITY
DCIF Re ce ive d
Jurisdiction
COMPLAINT FORM
By: _____________
Yes
No
Date : ____________
Case # ____________
This form is to be used for complaints against the Missouri Department of Labor and Industrial Relations (DOLIR) or its employees in
the provision of services to the public or for complaints by DOLIR employees concerning DOLIR administration, supervisors, or other
employees.
This form is not to be used for filing complaints with the Missouri Commission on Human Rights (MCHR) under the Missouri Human
Rights Act (MHRA). For information regarding MCHR and MHRA, visit labor.mo.gov/discrimination.
COMPLAINT INFORMATION
(Please print)
First Name
Last Name
Social Security Number (Voluntary)
Address
Home Phone (Include Area Code)
Other Phone (Include Area Code)
City
State
Zip Code
Email Address
What is the most convenient time and place for us to contact you about this complaint?
a.m.
p.m.
To the best of your recollection on what date(s) did the
Date of First Occurrence
Date of Most Recent Occurrence
discrimination take place?
Basis of Complaint: Which of the following best describes why you believe you were discriminated against. (Check ALL that apply.)
Race
Religion
Reprisal/Retaliation
Political
Color
Disability
National Origin
Citizenship
Age: Date of Birth:
Other:
Sex:
Male
Female
Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved.
Be sure to include how other persons were treated differently from you. Also attach any written material pertaining to your case.
(Attach separate sheet if needed.)
Do you think the discrimination against you involved: (Check one)
Your previous employer?
OR
A Labor Department employee providing/not providing you with services or benefits?
If so, which of the following are involved?
Appeal – Tax
Overpaid Benefits
Appeal – Tax Intercept
Reporting Requirements
Appeal – Lottery Intercept
Request for Confidential Information
Benefit Payments
Request to Reconsider a Denial of Benefits
Collecting Overpaid Benefits
Questions Regarding TAA/TRA
Collections
Questions Regarding Self-employment/Employment
Contributions Field Auditors
Verification of Social Security Number
Filing a New/Renewed/Weekly Claim
Wage Adjustments in Base Period of Claims
Investigation/Adjudication of a Work Separation or Job Refusal
Waiver of Work Search Requirement if Recall Date
Investigation/Adjudication on Able/Available/Schooling
Other: _____________________________________
Other Investigations/Adjudication
_____________________________________
MODOL-4519 (03-20) AI
H.Rel.
What other information (if any) do you think is relevant to our investigation? (Attach separate sheet, if needed.)
If this complaint is resolved to your satisfaction, what remedies do you seek? (Attach separate sheet, if needed.)
Please list below any persons (witnesses, fellow employees, supervisors, or others) that we may contact for additional information to
support or clarify your complaint: (Attach separate sheet, if needed.)
Phone No. (Area Code)
Name
Address
Do you have an attorney?
Yes
No
Attorney’s Name
Attorney’s Address
Attorney’s Phone Number
(Area Code)
Have you filed a case or complaint with any of the following?
U.S. Equal Employment Opportunity Commission
Missouri Commission on Human Rights
For each item checked at the right,
Civil Rights Division, U.S. Department of Justice
please provide the following information:
Civil Rights Center, U.S. Department of Labor
(Attach separate sheet if more than one is checked.)
Agency
Date Filed
Case or Docket Number
Location of Agency or Court
Date of T rial or Hearing
Name of Investigator
Status of Case
Comments
Have you been provided with a final decision at the Federal level regarding your complaint?
Yes
No
(Complaint NO T valid unless signed): Please Note: If you elect to file your complaint with the DOLIR, you must wait until the DOLIR issues a
decision or until 90 days have passed, whichever is sooner, before filing with the U.S. Department of Labor, Civil Rights Center (CRC), 200
Constitution Avenue, NW, Room N-4123, Washington DC 20210. If the DOLIR has not provided you with the written decision within 90 days of
the filing of the complaint, you need not wait for a decision to be issued, but may file a complaint with the CRC within 30 days of the expiration of
the 90-day period. If you are dissatisfied with the resolution of your complaint, you may file a complaint with the CRC. Such complaints must be
filed within 30 days of the date you received notice of the resolution.
Signature
Date
Send completed form to:
Jennifer Terry, Equal Opportunity Officer
Department of Labor and Industrial Relations
P.O. Box 510
Jefferson City, MO 65102-0510
Phone: 573-751-1339
Fax: 573-751-3668
Email: EO@labor.mo.gov
Missouri Department of Labor and Industrial Relations is an equal opportunity employer/program.
TDD/TTY: 800-735-2966 Relay Missouri: 711
MODOL-4519-2 (03-20) AI
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