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United States Department of Labor Office of Federal Contract Compliance Programs

Complaint Involving Employment Discrimination by a Federal Contractor or Subcontractor

OMB: 1250-0002
Expires: 5/31/2020

How can we reach you?

Have you filed these allegations of employment discrimination with another federal or local agency?

Who can we contact if we cannot reach you?

What is the name of the employer that you believe discriminated or retaliated against you?

Why do you believe your employer discriminated or retaliated against you?

How did you learn that you could file a complaint with OFCCP?

Your Complaint:

Please describe below what you think the employer did or didn't do that you believe caused discrimination or retaliation, including:

  1. What actions the employer took against you.
  2. Why you believe those actions were based on your: race; color; religion; sex; sexual orientation; gender identity; national origin; disability; veteran status; and/or inquiries about, discussions, or disclosures of your pay or the pay of others; and/or in retaliation for filing a complaint, participating in discrimination proceedings, opposing unlawful discrimination, or exercising any other rights protected by OFCCP.
  3. When the employer actions happened, where they happened, and who was involved.
  4. What harm, if any, you or others suffered because of the alleged discrimination or retaliation.
  5. What explanation, if any, your employer or people representing your employer offered for their actions.
  6. Who was in the same or similar situation as you and how they were treated. Include information such as the race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected status of these individuals, if known.
  7. What information you have about federal contracts the company that you worked for had at the time of the discrimination or retaliation you describe in this complaint.

Do you think the discrimination includes or affects others?

Do you believe other employees or applicants were treated the same way as you described above?

Do you have an attorney or other representative?

If you are represented by an attorney, or another person, or an organization, please provide their contact information below.

Who should we contact if we need more information about your description of what occurred?

Signature and Verification

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)