| Your Position: |
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| Your Duties: |
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| Salary/Wages: |
per hr.
per mo.
per yr. |
| Your Start Date: |
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| Do you have a written Contract?
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| Do you feel that you are the victim of discrimination?
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| If so, was the discrimination on the basis of:
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| Why do you believe you are the subject of discrimination?
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| Is there sexual or racial harassment going
on in the workplace?
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| If so, provide details:
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| Do you believe you are being retaliated against for some
action related to your employment? |
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| If so, Please provide the details:
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| Do you feel you are being targeted because you know
about illegal or improper conduct by your employer [i.e. whistle blower]? |
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| If so, please provide the details:
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| Date of last incident of discrimination/retaliation/harassment:
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| Please provide a summary of the events leading up to the
last incident:
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| Did you file an internal grievance?
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| If so, what did your internal grievance state, when
did you file and with whom?
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| Are you a member of a Union?
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| Have you filed a Union grievance?
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| If so, what was the result of your Union grievance?
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| Have you filed a complaint with the:
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| If so, what is the status of your complaint?
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| Have you received any written or oral warnings about your
work? Describe.
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| Please include any additional comments you may want to include:
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| Have you had or do you have a myspace page, blog, or any other personal webpage?
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| If so, please identify the URL where that page or pages can be found.
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| How did you learn about us? |
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| If none of the above, please describe how you found out about us.
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