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Intake Inquiry Form

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Intake Inquiry Form:

State of Nevada
Department of Employment, Training & Rehabilitation

Nevada Equal Rights Commission

Before completing this form, please contact the nearest Equal Rights Commission Office for instructions

Las Vegas - NERC
Phone (702) 486-7161
Reno - NERC
Phone (775) 823-6690

 

Intake Inquiry Form

The Nevada Equal Rights Commission is charged with the enforcement of employment, housing and public accommodations, state and federal discrimination laws, under NRS 233 and 613 inclusive; Title VII of the Civil Rights Act of 1964, as amended; Age Discrimination in Employment Act of 1967, as amended; and Equal Employment Opportunity Commission procedural regulations; housing NRS 118 and Public Announcement NRS 651.

NOTE: Your complaint must be filed within 300 days from the last alleged discriminatory act. The company against whom you are claiming discrimination must employ a total of 15 or more employees (total workforce - Nevada and elsewhere).

*** Fields marked with an asterisk "*" are required. ***  Please enter all dates as: MM/DD/YYYY. Phone numbers - must enter area code.

Section A:

*Mr./Mrs.:
*First Name: *Last Name:
*Birth Date:    
       
Mailing Address:    
*Street: Apt/Space/Room:
*City: *State:
*Zip Code: Email:
Home Phone: Cell Phone:
  (enter area code+number)   (enter area code+number)  
Do you need the assistance of an interpreter?: Yes: (If YES, what language?:) 

 

Section B:

*Company Name:    
  (Name of the company that you believe discriminated against you.)    
Physical Address:   Company Phone:
          (enter area code+number)
*Street: Apt/Space/Room:
*City: *State: *Zip Code:

 

Section C:
Give the name of someone who does not live with you and would be able to help us reach you.
 
Relationship: Telephone:
          (enter area code+number)
First Name: Last Name:
Physical Address:    
Street: Apt/Space/Room:
City: State: Zip Code:

 

Section D:
 
*Hire Date:

Last Date Worked: 

*Date of alleged Discriminatory act:

*Present/ending position title: 

*Present/Ending Pay: $

*per 

  (Enter $17.25 as 1725)    

 

Section E:
This is a complaint of discrimination based upon:
(Mark only the reasons which you believe caused the discriminatory act(s) that you are claiming.)
 
Race
Color
Religion
Disability
Age (40 and over)
National Origin
Sex
Sexual Orientation
Retaliation
Gender Identity or Expression

If box checked, explanation is required in associated text box.

 

Section F: 
Mark only those actions allegedly taken against you AND the date of last alleged occurrence:
Demotion Discharge
Lay off Fail to Hire
Harassment Forced Resignation
Fail to Promote Sexual Harassment
Failure to Compensate Fail to Represent (Union)
Failure to Accommodate
Pregnancy/Maternity (leave forced or denied)
Terms & Conditions of Employment (brief explanation)
If box checked, explanation is required in associated text box.

 

Section G : 
List the name(s) of the individual(s) that you are claiming were involved in the alleged discrimination:

 
First Name: Last Name: Job Title:
First Name: Last Name: Job Title:
First Name: Last Name: Job Title:
           

 

Section H: 
What is the name of the company's Human Resources or Personnel Manager?

 
First Name: Last Name: Telephone Number:
          (enter area code+number)
           

 

Section I: 
List the name(s) of anyone who witnessed, observed, and/or has knowledge of the event(s) that you are claiming were acts of discrimination.  Give the names of those people who would willingly give a statement and would support you as your witness.  NOTE:  All witness testimony in this process is voluntary.

 
First Name: Last Name:
Address:
City: State:
Zip Code: Telephone Number:
      (enter area code+number)
       

First Name: Last Name:
Address:
City: State:
Zip Code: Telephone Number:
      (enter area code+number)
       

First Name: Last Name:
Address:
City: State:
Zip Code: Telephone Number:
      (enter area code+number)
       

First Name: Last Name:
Address:
City: State:
Zip Code: Tele phone Number:
      (enter area code+number)
       

First Name: Last Name:
Address:
City: State:
Zip Code: Telephone Number:
      (enter area code+number)
       

 

Section J: 

Complete these sentences:  *** All fields are required
 
1) I was hired by company on or about

Name of Company/business

  as a . While employed there, I was subject to
         

(Describe the type of discrimination/conditions that you are alleging happened)

 

by

my

 

(The primary person in your complaint)

(That person's job title - co-worker, supervisor, etc.)

  After the last alleged discriminatory event, I filed my complaint with the Nevada Equal Rights Commission.
         
2) The company explained that I was treated in this way because:
 
   
3) I believe I was treated this way because:
 
   
4) Explain the alleged discriminatory event(s) that you have marked in Section E.  Please include who did what, who was there, what happened, when it happened, where it happened, what was said, etc.  Please be as brief as possible.
 
   
         
  (To get a copy print before submitting)  
 

 

         

 

 

Department of Employment, Training and Rehabilitation
Nevada Equal Rights Commission

1820 East Sahara Ave,  Suite 314
Las Vegas, NV 89104

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