Preventing Sexual Harassment in the Workplace for Illinois Professionals, 2nd Edition _ _________________
STATE OF ILLINOIS – DEPARTMENT OF HUMAN RIGHTS: COMPLAINT INFORMATION SHEET
COMPLAINANT INFORMATION SHEET (For All Cases not related to Housing Discrimination)
State of Illinois Department of Human Rights Office Use Only:
Date:
Control No:
Inv. Init.
_______________________ Instructions: Read this entire form and all of the instructions carefully before completing. All questions should be answered, and you may use additional sheets if necessary. This form must be signed and dated on page 4, and postmarked or received by IDHR within 300 days of the date of the alleged discrimination. IDHR must establish if it has the right under the law to investigate your claim. If IDHR accepts your claim of discrimination, we will type your information on an official charge form. The official charge form must be signed under certification or notarized and returned to IDHR in a timely manner. THIS IS NOT A FORMAL CHARGE. If IDHR accepts your claim, we will send you an official typed charge form for signature. NOTE: If your alleged claim of discrimination is related to Housing, e.g., in buying or renting a house or apartment , or experiencing a refusal to a r equest to modify your housing, please STOP and fill out an IDHR Housing Complainant Information Sheet (CIS) . 1. COMPLAINANT INFORMATION
Address:
Apt No:
Name:
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PhoneNo:
Alt. Phone No: E-Mail: E-Mail Consent: By checking this box, I con s ent to service of notices by the Department via electronic mail.
Alt. Phone No:
Please provide the following information for statistical purposes only. Country of National Origin:
Sex:
Date of Birth:
2. WHO CAN WE CALL IF WE CANNOT CONTACT 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 we are unable to locate you.
Name:
Address:
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Address:
Apt No:
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3. RESPONDENT INFORMATION Write out the full legal name of the company or organization that you believe discriminated against you in Illinois (i.e. the Respondent). (Employer, Employment Agency, Financial Institution, Union, Place of Public Accommodation, School or University, etc.)
Name:
Address:
PhoneNo:
State:
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Website:
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4. WHAT IS YOUR RELATIONSHIP WITH THE RESPONDENT
EMPLOYMENT: Respondent is my Employer / Former Employer / Potential Employer.
PUBLIC ACCOMMODATIONS: Respondent is a Public Entity or Place of Business (of which I am not a current, former, or potential employee), such as a Store, Restaurant, Public Park, Educational Program, or Public Official, and has denied me a service or access or has subjected me to a form of pervasive harassment. SEXUAL HARASSMENT IN EDUCATION: Respondent is or represents an Educational Institution in which I (or my minor child) am currently, recently, or I have applied to be enrolled that I believe has sexually harassed me (or my minor child), or has retaliated against me (or my minor child) for reporting, opposing or for participating in an investigation of sexual harassment. NOTE: If the Respondent is an employer, does the Respondent employ 15 or more employees in the Unites States? FINANCIAL CREDIT: Respondent is a Financial Institution, such as a bank or an insurance company, to which I applied for an account or line of credit. Yes No
What type of business or organization is the Respondent? For example, a Private Employer, Public or Non-Profit Organization, State or Local Government, School or University (specify Public or Private, and if it is Elementary, Secondary, Vocational, etc., and your current enrollment status), Employment Agency, Municipality, Union, Bank, Insurance Company, Individual, etc.
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555 West Monroe Street, 7th Floor, Attn. Intake Unit, Chicago, IL 60661 ; 312-814-6200; 866-740-3953 (TTY); INTERVIEWS MON.-THURS. 8:30 AM to 3:00 PM In Springfield: 5 24S2nd Street, 3rd Floor, Attn. Intake Unit, Springfield, IL 6270 1 ; 217-785-5100; 866-740-3953 (TTY) WEBSITE: www.illinois.gov/dhr/ EMAIL: IDHR.Intake@illinois.gov CHICAGO FAX: 312-814-6251 SPRINGFIELD FAX: 217-785-5106
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