Complaint Involving Employment Discrimination by a Federal Contractor or Subcontractor

OMB: 1250-0002
Expires: 5/31/2023

How can we reach you?

Name (First, Middle, Last):

Street Address:

City:

State:

Zip Code:

Telephone Number:

Home

Work

Cell

E-mail:

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

Yes

If yes, provide the agency and date filed:

Contact Name:

Phone Number:

Who can we contact if we cannot reach you?

Name (First, Middle, Last):

Street Address:

City:

State:

Zip Code:

Telephone Number:

Home

Work

Cell

E-mail:

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

Company Name:

Street Address:

City:

State:

Zip Code:

Telephone Number:

Give the date(s) and times you believe you were discriminated against:

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

Internet

Poster

Community Organization

OFCCP Meeting/Event

Brochure

Other

Your Complaint:

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

What actions the employer took against you.
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.
When the employer actions happened, where they happened, and who was involved.
What harm, if any, you or others suffered because of the alleged discrimination or retaliation.
What explanation, if any, your employer or people representing your employer offered for their actions.
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.
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?

Yes

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.

Name (First, Middle, Last):

Street Address:

City:

State:

Zip Code:

Telephone Number:

E-mail:

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

You

Your Representative

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.

Signature of Complainant:

Date:

Form CC-4 (Revised 5/2020)

Complaint Involving Employment Discrimination by a Federal Contractor or Subcontractor

How can we reach you?

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:

Do you think the discrimination includes or affects others?

Do you have an attorney or other representative?

Signature and Verification