U.S. Equal Employment Opportunity Commission

Intake Questionnaire

Filling out and bringing us or sending us this questionnaire does not mean that you have filed a charge. If you want to file a charge about job discrimination, there are time limits to file the charge. In many States that limit is 300 days from the date you knew about the harm or negative job action, but in other States it is 180 days. To protect your rights, it is important that you fill out the questionnaire, sign it, and bring it or send it to us right away.

This questionnaire will help us determine if you are covered by the laws we enforce.  If you live within 50 miles of an EEOC office, we recommend that you bring the completed questionnaire to us to discuss your situation. If you mail the completed questionnaire to us, someone from the EEOC should contact you by mail or by phone within 30 days. If you don't hear from us in 30 days, please call us at 1-800-669-4000.

Download the intake questionnaire here (requires the free Adobe Acrobat Reader  or another Adobe Acrobat product):

The questionnaire is NOT a fillable PDF form. When you have completed the form, please PRINT it, sign it and mail to the appropriate EEOC office.