TAQ Employment Form to Florida Commission on Human Relations

FCHR Employment Technical Assistance Questionnaire
1. Personal Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
(or Country name if out of the states)
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
E-mail*
Date of Birth*

MonthDayYear
Date
Gender Identity*

FemaleMaleNon-BinaryOther
2. Please provide the name of a person we can contact if we are unable to reach you
Contact Name*

First NameMiddle NameLast Name
Relationship*
Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
3. Discrimination Information
I believe that I was discriminated against by the following organization(s):*

EmployerUnionEmployment AgencyOther
Organization Contact Information (If the organization is an employer, provide the address where you actually worked. If you work from home, check the box □ and provide the address of the office to which you reported.) If more than one employer is involved, you must fill out a separate Technical Assistance Questionnaire form for each employer.

I work from Home
Organization Name
Address of the Organization

Street Address

Street Address Line 2

CityState

Zip Code
County*
(or Country name if out of the states)
Organization's Phone Number

Area CodePhone Number
Type of Business
Job location if different from Organization's Address
Human Resources Director/Owner Name
HR/Owner phone number

Area CodePhone Number
Does the organization employ 15 or more employees? (include all locations/branches/offices)*

YesNoNot Sure
4. Your Employment Data (complete as many items as you are able)
Date hired*

MonthDayYear
Date
Job Title at hire
Job Title at time of alleged discrimination
Date of Harm / Quit / Discharged*

MonthDayYear
Date
Name and Title of immediate supervisor
If Job applicant, Date applied for job

MonthDayYear
Date
Job Title applied for
Are you a Federal employee?*

YesNo
5. Have you been discriminated against due to one or more of the following? FOR EXAMPLE, if you feel that you were treated worse than someone else because of race, you should check the box next to Race. If you feel you were treated worse for several reasons, such as your sex, religion and national origin, check all that apply. If you complained about discrimination, participated in someone else’s complaint or filed a charge of discrimination and a negative action was threatened or taken, you should check the box next to Retaliation.
Race

BlackWhiteAsianNative Hawaiian/Pacific IslanderAmerican Indian or Alaska Native
Color

Light ComplexionDark ComplexionOther
National Origin

HispanicMexicanArab/Afghan/Middle EasternEast indianOther
Marital Status

MarriedSingleDivorcedWidowed
Sex

FemaleMale
Pregnant or condition related to pregnancy or childbirth

Yes
Sexual Orientation

Yes
Gender Identity

Yes
Age

Under 40 years old40 years or older
Retaliation

Yes
Religion (Please identify)
Disability/Handicap

Yes
Genetic Information - Check mark which type(s) of genetic information is involved

Genetic testingFamily medical historyGenetic services (counseling, education or testing)
If you checked genetic information, how did the employer obtain the genetic information?
6. What happened
What happened to you that you believe was discriminatory? Include the date(s) of harm, the action(s), and the name(s) and title(s) of the person(s) who you believe discriminated against you. Please fax or email additional pages if needed. (Example: 08/08/2011 – Discharged by Mr. John Smith, Supervisor) - Explain here*
7. Have you filed a charge previously
Have you filed a charge previously on this matter with the EEOC or another agency?*

YesNo
If so, provide the name of the agency and the date of filing:
8. Attorney
Are you currently represented by an attorney?*

YesNo
If yes, please provide name, address, telephone number and email address

0/160
Mail or Fax to:

Florida Commission on Human Relations
4075 Esplanade Way, Room 110
Tallahassee, Florida 32399-7020
Telephone (850) 488-7082
Facsimile (850) 487-1007
Please, scroll up to review your information before you click "Submit", or to continue later, click "Save" button and you will get an email with the link to come back to this form.
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FCHR Employment Technical Assistance Questionnaire

1. Personal Information

2. Please provide the name of a person we can contact if we are unable to reach you

3. Discrimination Information

4. Your Employment Data (complete as many items as you are able)

6. What happened

7. Have you filed a charge previously

8. Attorney