Please read the instructions before completing this form.
OMB: 1250-0002Expires: 5/31/2020
Please describe below what you think the employer did or didn't do that you believe caused discrimination or retaliation, including:
If you are represented by an attorney, or another person, or an organization, please provide their contact information below.
I declare under penalty of perjury that the information given above is true and correct to the best of my knowledge or belief. A willful false statement is punishable by law.
I hereby authorize the release of any medical information needed for this investigation.
Form CC-4 (Revised 5/2017)