EEOC Charge of Discrimination Template

U.S. Equal Employment Opportunity Commission

1. Charging Party Information

• Name:
• Address:
• City/State/ZIP:
• Phone:
• Email (optional):
• Date of Birth:

2. Employer/Respondent Information

• Employer/Organization Name:
• Address:
• City/State/ZIP:
• Phone:
• Number of Employees (approx.):
• HR Contact (if known):

3. Cause of Discrimination (check all that apply)

• ☐ Race
• ☐ Color
• ☐ Religion
• ☐ Sex (including pregnancy, sexual orientation, gender identity)
• ☐ National Origin
• ☐ Age (40 or older)
• ☐ Disability
• ☐ Genetic Information
• ☐ Retaliation
• ☐ Other: ____

4. Date(s) of Discrimination

• Earliest: [MM/DD/YYYY]
• Latest: [MM/DD/YYYY]
• ☐ Continuing Action

5. Statement of Harm

Provide a concise narrative of events (attach additional pages if needed):
- Position/title and tenure with employer.
- Description of discriminatory acts (harassment, demotion, termination, failure to accommodate, retaliation).
- Names and titles of individuals involved.
- Witnesses or evidence supporting claim.
- Impact on employment, pay, benefits, or working conditions.

6. Relief Sought

• Reinstatement, back pay, front pay.
• Policy changes, training, accommodations.
• Compensatory damages (emotional distress), punitive damages.

7. Prior Proceedings

• Have you filed with a state or local fair employment agency? ☐ Yes ☐ No
• Agency name and date filed:
• Have you filed a union grievance or internal complaint? ☐ Yes ☐ No (describe outcome).

8. Representation

• Are you represented by an attorney? ☐ Yes ☐ No
• Attorney name, firm, contact information.
• Authorization for attorney to receive correspondence on your behalf.

9. Verification

• I declare under penalty of perjury that I have read the above charge and that it is true to the best of my knowledge, information, and belief.

Charging Party Signature: ____ Date: __

EEOC Official Use Only: Charge Number _ Date Filed _

Instructions: Submit this charge to the EEOC via online portal, mail, or in-person at local field office. Retain copies of supporting documents (emails, performance reviews, medical documentation).