Employment / Grant Funded Service Discrimination Complaint Form

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State of Illinois Illinois Criminal Justice Information Authority
State of Illinois
Illinois Criminal Justice Information Authority
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1. CONTACT INFORMATION:
Sex:
CHECK THE CATEGORY IN THE LIST BELOW OF NATIONAL ORIGIN OR ANCESTRY WITH WHICH YOU MOST STRONGLY IDENTIFY:
3. ALTERNATE CONTACT INFORMATION: Provide the names of two persons who can contact you in the event this office is unable to locate you. Make sure their mailing addresses are different from your mailing address. Your charge could be dismissed if you do not provide this information and you are unable to be located.
ALTERNATE CONTACT INFORMATION #2:
4. Are you alleging you were discriminated against in: *This question is required.
5. RESPONDENT INFORMATION: Write out the full legal name of the Employer, Union, Employment Agency, Temporary Agency (i.e. the Respondent), that you believe discriminated against you in Illinois.
RESPONDENT INFORMATION #2:
Does the Respondent Have a Total of 15 or More People Working in the State of Illinois?
Does the Respondent Have a Total of 15 or More People Working in the United States?
6. IF YOU HAVE BEEN EMPLOYED BY THE RESPONDENT, PLEASE FILL IN THE FOLLOWING:
Were you on probation?
Salary Type (Select One):
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8. WITNESS INFORMATION:
WITNESS INFORMATION #2:
9. Have you filed a previous charge against this Employer on this matter with the Equal Employment Opportunity Commission?
Do you want the sexual harasser charged separately as additional respondent?
If yes, give the address of that person:
11. Have you filed a previous charge against this Employer with the Illinois Department of Human Rights?
Location where services are being provided:
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The Illinois Criminal Justice Information Authority (Authority) will forward this form to the Illinois Department of Human Rights (IDHR) and/or US Department of Justice (US DOJ), Civil Rights Division.


Notice to complainant on release of identity and personal information. The Illinois Human Rights Act (“Act”), 775 ILCS 5/1-101 et seq., and Section 2520.330 of IDHR's Rules and Regulations, 56 Ill. Admin. Code, Ch. II, Section 2520.330, require a charge to contain certain information in such detail as to substantially apprise the parties of the time, place, and facts with respect to the alleged civil rights violation. Pursuant to the Department's Rules and Regulations (2 Ill. Admin Code, Ch. X, Section 926.210), anyone who submits information to IDHR in connection with a discrimination charge should take notice and be aware of the following: (a) All contents and files maintained by IDHR pertaining to charges shall be confidential and not subject to public disclosure. Relevant exceptions are: 1) the parties to a charge may inspect the file at any time subsequent to the written notice of substantial evidence, default, or dismissal, administrative closure, or approval of terms of settlement by the Human Rights Commission (“Commission”); 2) after the filing of a Complaint with the Commission or the institution of judicial proceedings involving a charge, the Director may release information pertaining to the charge if such information is requested of IDHR or if the Director finds such information newsworthy, useful in education or training, relevant to an issue before the General Assembly, or similarly appropriate for disclosure. (b) Authorized personnel within IDHR analyze information that IDHR collects. This information may include personal information. IDHR staff may need to reveal some of the personal information to individuals outside the office in order to verify facts related to the charge, or to discover new facts which will help IDHR to determine whether the law has been violated. IDHR may need to disclose to Respondent correspondence that IDHR receives from Complainant or other sources. (c) IDHR may release the identity and personal information of the parties pursuant to a Freedom of Information Act (“FOIA”) request, a subpoena or a court order, and information submitted to or obtained by IDHR may also be revealed to persons outside of IDHR to enforce a Commission Order or a settlement agreement. (d) No person is required to file a charge with IDHR and reveal personal information to IDHR; however, if a person files a charge and IDHR cannot obtain the information needed to fully investigate the allegations in the charge, IDHR may close the case.


By submitting this form, you agree that you have read the “Notice to Complainant” above and understand that: 1) The Authority does not investigate charges of discrimination; 2) The Authority will forward all information from this form to the IDHR and/or US DOJ, Civil Rights Division; 3) IDHR may also file my charge of discrimination with EEOC if it has jurisdiction, and you authorize EEOC to look into the discrimination alleged above; 4) In the course of investigating your charge, IDHR will reveal your identity (including your name) and your personal information to named Respondent(s) in your charge to obtain facts and evidence regarding your charge; 5) you do not have to reveal your personal information to IDHR, but IDHR may close your charge if you refuse to reveal information needed to fully investigate your charge; 6) IDHR may be required by law, subpoena, court order, and/or Freedom of Information Act request to disclose your charge and information in the Department's investigation file concerning your charge to persons outside of IDHR. If IDHR takes a charge based on the information provided, you consent for IDHR to disclose your identity and personal information as necessary to process and investigate my charge, and you release the Authority and IDHR from any liability whatsoever concerning disclosure of your identity and any personal information you provided to the Authority, IDHR or IDHR obtained in processing your charge. Clicking on the Submit button verifies the accuracy of the information provided herein and your consent and release as indicated above.