Employment Complaint

If you have not heard from an EEOC office within 30 days of submitting this form, please call (225) 342-6969.

PRIVACY ACT STATEMENT: This form is covered by the Privacy Act of 1974: Public Law 93-579. Authority for requesting personal data and the uses thereof are:

1. FORM NUMBER/TITLE/DATE. EEOC/FEPA Intake Questionnaire (10/2006).
2. AUTHORITY. 42 U.S.C. § 2000e-5(b), 29 U.S.C. § 211, 29 U.S.C. § 626. 42 U.S.C. 12117(a)
3. PRINCIPAL PURPOSE. The purpose of this questionnaire is to solicit information in an acceptable form consistent with statutory requirements to enable the Commission to act on matters within its jurisdiction. When this form constitutes the only timely written statement of allegations of employment discrimination, the Commission will, consistent with 29 CFR 1601.12(b) and 29 CFR 1626.8(b), consider it to be a sufficient charge of discrimination under the relevant statute(s).
4. ROUTINE USES. Information provided on this form will be used by Commission employees to determine the existence of facts relevant to a decision as to whether the Commission has jurisdiction over allegations of employment discrimination and to provide such charge filing counseling as is appropriate. Information provided on this form may be disclosed to other State, local and federal agencies as may be appropriate or necessary to carrying out the Commission’s functions. Information may also be disclosed to respondents in connection with litigation.
5. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL FOR NOT PROVIDING INFORMATION. The providing of this information is voluntary but the failure to do so may hamper the Commission’s investigation of a charge of discrimination. It is not mandatory that this form be used to provide the requested information.

1. I understand that I am not required to give personal information to the LCHR; however, my complaint may be closed if I refuse to supply information needed to investigate my complaint;
2. I understand that it is my duty to update the personal information I supply and failure to do so may result in my complaint being closed;
3. I understand that I may receive a copy of any personal information I submit, if I request it; and
4. I understand that the information provided by me may have to be released under the Public Records Request.

Based on the foregoing, I hereby give my consent to LCHR to process my complaint.