Small Employer Employment Discrimination
Complaint Online Questionnaire Form

• Business/employer located within the city of Phoenix boundaries
• The employer has 14 or fewer employees
• The incident occurred within the past 180 days.

For further information visit: http://phoenix.gov/EOD/discempl.html

Name:* Home Address: City: State: Zip: Work Address: City: State: Zip: Company Name:*	Best time to call:	Home phone:* Work phone: Cell phone: Pager:
E-mail address:	Today's date:* (mm/dd/yyyy)
If applicable to your complaint of discrimination, what is your: Race National Origin Religion Gender Color Sexual Orientation Marital Status
Number of employees locally:*	Number of employees nationally:*

Please identify potential witnesses by name, title and department. Include address and phone number where known:

Witness name:	Daytime phone:
Address:	Cell/Evening phone:
Witness name:	Daytime phone:
Address:	Cell/Evening phone:

What happened to you? Please include dates, witnesses and/or comparative employees who were treated differently. How were you discriminated against? For example: Were you terminated, not selected for a position, demoted or treated differently in the terms and conditions of your employment?*

Why do you believe you are being discriminated against? It is a violation of the law to discriminate against, or harass in any aspect of employment for the following reasons: race, sexual orientation, color, religion, gender, national origin, or marital status. Briefly explain why you think your employment rights were denied because of any of the factors listed above.*

Who do you believe discriminated against you? Was it your supervisor, a co-worker or subordinate?

Name:
Title/Position:
Address:
City:   State:   Zip code:

If applicable, what is that persons:   
Race National Origin
Religion Gender Sexual Orientation
Color Marital Status

Is the alleged discrimination ongoing? Yes No

When did the last act of discrimination occur? Enter the date (mm/dd/yyyy)*

* Required fields

Use the submit button below to e-mail your completed form to the intake officer: eod.complaint.enforcement@phoenix.gov

If you prefer, you may call, mail or fax the completed questionnaire to the Equal Opportunity Department at:

City of Phoenix Equal Opportunity Department
Compliance & Enforcement Division
251 W. Washington St. 7th Floor
Phoenix, AZ 85003
602-262-7486/voice     602-534-1557/TTY     602-495-0517/fax

The Equal Opportunity Department will make every attempt to contact you within 48 hours of receipt of your complaint.

Contact information for employers outside of Phoenix or who have more than 14 employees:

Within 180 days from the most recent alleged discriminatory incident:
Arizona Attorney General's Office, Civil Rights Division,
1275 W. Washington
Phoenix, Arizona 85003
(602) 542-5263

Within 300 days from the most recent alleged discriminatory incident:
U.S. Equal Employment Opportunity Commission, Phoenix District Office
3300 N. Central Ave., Suite 690
Phoenix, Arizona 85012
(602) 640-5000