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Discrimination Charge Form

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DISCRIMINATION CHARGE FORM

Charging Party Name:   Date of Birth:

Charging Party Address:

Telephone:   Email:

Respondent (Employer/Institution) Name:

Respondent Address:

Respondent Contact Person/Title:   Telephone:

RECITALS

WHEREAS, Charging Party alleges that Respondent engaged in employment or service-related practices that discriminate on the basis of one or more protected characteristics identified below; and

WHEREAS, Charging Party seeks a formal administrative charge to initiate an investigation, obtain relief, and preserve legal rights under applicable anti-discrimination statutes and regulations; and

WHEREAS, Respondent is subject to the jurisdiction of the agency receiving this charge by reason of its operations and the alleged discriminatory acts occurring within the agency's enforcement authority.

NOW, THEREFORE

NOW, THEREFORE, Charging Party submits this formal Charge of Discrimination and states the following under penalty of perjury:

1. JURISDICTION

Charging Party contends that the acts complained of occurred within the time period and geographic scope necessary to invoke the investigative authority of the relevant administrative body and are alleged to violate applicable federal, state, and local statutes prohibiting discrimination in employment, public accommodations, housing, or education as may be appropriate.

2. BASIS OF DISCRIMINATION (CHECK ALL THAT APPLY)

           
        
If Other, explain:

3. NATURE OF ALLEGATIONS

Specify the type of adverse action alleged (select all that apply):
        
        
If Other, describe:

4. TIMELINE OF INCIDENTS

Provide the date of the first adverse act:

Provide the date of the most recent adverse act (if ongoing):

List additional incident dates and brief descriptors (separate entries with semicolons):

5. FACTUAL STATEMENT

Provide a clear and concise statement of the facts describing the alleged discriminatory acts, including names, positions of individuals involved, location of occurrences, and any actions taken by Charging Party to report or resolve the matter prior to filing this charge.

6. WITNESSES AND DOCUMENTS

Names and contact information for witnesses who may corroborate your allegations:

Describe documents or evidence you are submitting or intend to produce (performance evaluations, emails, policies, medical records, payroll records, etc.):

7. RELIEF REQUESTED

Specify the remedy or relief sought (e.g., reinstatement, back pay, compensatory damages, injunctive relief, policy changes, other):

8. REPRESENTATION

Are you represented by an attorney or another representative?      

9. NOTICES

All official correspondence regarding this Charge shall be sent to the primary mailing address and email provided above unless a different mailing address is specified below.

10. CERTIFICATION AND ACKNOWLEDGEMENT

I certify that the information provided in this Charge of Discrimination is true and correct to the best of my knowledge. I understand that knowingly providing false information may subject me to penalties under law. I consent to the release of information necessary for the processing and investigation of this charge, including disclosure to the Respondent and other relevant parties as required by the investigative process.

I further understand that filing this Charge initiates an administrative process; it may result in investigation, mediation, conciliation, or other proceedings as determined by the receiving authority. Filing this Charge does not guarantee a particular outcome or award of relief.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Charge shall be governed by applicable federal, state, and local anti-discrimination laws. This instrument constitutes the complete and entire statement of the allegations and requested relief as submitted by Charging Party in this filing. If any provision of this Charge is held invalid or unenforceable, the remainder of this Charge shall remain in full force and effect.

12. AMENDMENTS; WAIVER; COUNTERPARTS

This Charge may be amended or supplemented by written submission of additional facts or documents. Failure to timely assert any right or request shall not constitute a waiver of that right. This Charge may be executed in counterparts and transmitted by facsimile or electronic reproduction, each of which shall be deemed an original for all purposes.

SIGNATURES

Charging Party Printed Name:

By:

Date:

Agency / Authorized Representative Printed Name:

By:

Date:

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What the Discrimination Charge Form Is and When it Applies

The Discrimination Charge Form is the official complaint used to notify a civil rights enforcement agency of alleged unlawful discrimination based on protected characteristics such as race, sex, religion, age, disability, national origin, or pregnancy. Complainants typically file with the U.S. Equal Employment Opportunity Commission (EEOC) or a state Fair Employment Practices Agency (FEPA), which may investigate, mediate, or issue right-to-sue notices. The form records identifying details, the employer or respondent, incident dates and a concise description of the alleged acts. Electronic completion and submission are generally permitted under U.S. e‑signature laws such as ESIGN and state UETA statutes when the agency accepts digital filings.

Why a Properly Completed Charge Matters

Filing a clear Discrimination Charge preserves legal rights, initiates an official review, and documents dates, witnesses, and relief sought. A complete form helps agencies determine jurisdiction and speeds intake, while incomplete or late submissions can limit remedies or require corrections before investigation.

Why a Properly Completed Charge Matters

Who Typically Prepares or Receives This Form

The Discrimination Charge Form is used by individuals alleging discrimination and by agencies that process and respond to claims.

  • Employees or applicants alleging workplace discrimination who need to protect statutory rights and trigger agency action.
  • State and federal enforcement agencies (EEOC, state FEPAs) that intake, investigate, and mediate complaints.
  • Employers' HR and legal teams who receive notices and must preserve records and prepare a response for the agency.

Accurate completion supports timely processing by agencies and reduces the risk of procedural dismissal or jurisdictional gaps.

Common Signers and Responsible Parties

Complainant

The individual alleging discrimination. Provides personal information, incident details, preferred remedy, and signs the charge to confirm accuracy and intent to proceed.

Agency Representative

An intake officer or investigator from EEOC or a state agency records the agency case number, accepts the charge, and may sign or stamp agency receipt for administrative tracking.

Core Sections Included in a Professional Charge Form

A complete Discrimination Charge Form contains standard sections to ensure investigators can evaluate jurisdiction and begin fact-finding promptly.

Complainant Info

Full legal name, contact details, mailing address, and preferred method of contact to allow agency correspondence and serve notices.

Respondent Details

Employer or respondent name, address, and contact information so the agency can identify and notify the party under investigation.

Protected Basis

Clear indication of the alleged basis (for example, race, sex, disability) to align the claim with applicable statutes and investigative tracks.

Date(s) of Conduct

Specific dates or a date range for the alleged acts so the agency can assess filing windows and identify records to preserve.

Statement of Facts

Concise, chronological description of events, actions taken, and persons involved; names of witnesses when known for follow-up.

Relief Requested

Specify desired remedies such as back pay, reinstatement, policy change, or compensatory damages to guide agency mediation or remedy calculations.

Required Fields and Minimum Data Elements

Complainant name: Legal name
Contact details: Phone and mailing address
Employer name: Respondent identity
Incident dates: Exact or estimated dates
Basis of claim: Protected characteristic
Signature: Complainant attestation

Consequences of Errors or Missing Information

Missed filing window: Loss of remedies
Incomplete facts: Investigation delays
False statements: Potential sanctions or credibility harm
Wrong agency: Referral and filing delay
Privacy breaches: Exposure of sensitive information
Untimely amendments: Procedural rejection risk

Common Mistakes to Avoid When Preparing a Charge

  • Giving vague timeline details rather than specific dates, which makes it hard for investigators to identify relevant records and witnesses.
  • Failing to list witnesses or contact information, which can lengthen fact gathering and reduce the agency’s ability to corroborate claims.
  • Submitting partial or contradictory employer names or addresses, which can prevent proper service and delay the case opening.
  • Overloading the narrative with irrelevant history instead of a clear, concise sequence of discriminatory acts tied to dates and actors.

Step-by-Step: Completing a Discrimination Charge Form

Follow these practical steps to draft a clear, agency-ready charge that preserves your rights and supports efficient review.

  • 01
    Collect information: Gather names, dates, and witness contacts.
  • 02
    Describe incidents: Write a chronological, factual narrative.
  • 03
    Select basis: Choose one or more protected characteristics.
  • 04
    Sign and submit: Affirm accuracy and file with the appropriate agency.

How Filing and Intake Typically Work

Filing a charge starts intake, moves to jurisdiction review, and proceeds to investigation or mediation if the agency accepts the claim.

  • File with agency: Submit to EEOC or state FEPA for intake.
  • Agency intake: Agency screens for jurisdiction and completeness.
  • Investigation: Agency requests documents and interviews parties.
  • Resolution: Mediation, settlement, or right-to-sue letter follows.

Digital Workflow Settings for Online Completion

Configure a secure digital intake flow to capture mandatory fields, manage attachments, and save audit history for agency review.

Field Configuration
Complainant name Required | single-line text
Incident dates Required | date range field
Narrative Required | multiline text
Attachments Optional | PDF, DOCX allowed

Delivery Options and Platform Compatibility

Agencies accept charges by in-person filing, mail, fax, and increasingly by secure electronic submission when supported.

  • File formats: PDF and DOCX widely accepted
  • Authentication: Email or SMS verification common
  • Integrations: CRM and case management connectors

Ensure any platform used preserves an audit trail, secures personal data, and produces a retrievable signed copy for records.

Important Filing Deadlines and Timing Expectations

Timely filing is critical. Agencies apply different filing windows depending on whether state law supplements federal protections.

Federal EEOC window:

Generally 180 days from the alleged act; extended to 300 days in some jurisdictions

State FEPA window:

Many state agencies allow a 300-day filing period when state law applies

Agency intake time:

Initial intake and jurisdiction check typically completed within days to weeks

Investigation length:

Investigations vary; many close within 180 days but complex cases take longer

Right-to-sue notice:

If no resolution, the agency may issue a notice enabling civil court filing

Key Case Milestones from Filing to Resolution

These sequential milestones outline typical stages an agency-managed charge moves through after submission.

01

Report Incident

Complainant documents the alleged discriminatory acts with dates and witnesses for the record.

02

Prepare Charge

Draft a concise narrative and collect supporting documents before filing the formal charge.

03

File with Agency

Submit the charge to the EEOC or appropriate state agency for intake screening and assignment.

04

Investigation & Outcome

Agency investigates, attempts conciliation, and issues findings or right-to-sue as appropriate.

Realistic Use Scenarios and What They Look Like

These short scenarios illustrate typical filings and the documentation that supports them.

Retail Employee Charge

An associate documents repeated supervisory comments and denied promotion dates

  • Names two co-workers who witnessed the remarks
  • The charge includes payroll records and a concise timeline so the agency can quickly identify relevant evidence and open investigation.

Healthcare Staff Complaint

A clinician reports discriminatory scheduling and adverse evaluation following disclosure of a protected status

  • Lists specific dates and patients affected
  • The charge attaches performance reviews and requests confidentiality; the agency coordinates records requests with the employer to preserve patient privacy.

Practical Tips for Accurate and Efficient Filing

Follow these practices to reduce processing delays and to strengthen the administrative record for any eventual legal action.

Be chronological
Present events in date order, focusing on the most recent discriminatory acts, and avoid unrelated background details that distract from the central claims.
Attach supporting records
Include relevant documents such as performance reviews, termination letters, payroll receipts, and communications that corroborate dates and alleged actions.
List witnesses
Provide names and best contact information for witnesses to enable timely interviews and to strengthen investigative leads.
Preserve originals
Keep copies of all submitted materials, maintain an audit trail of electronic submission, and preserve relevant electronic messages and files.

Comparing eSignature Options for Preparing and Submitting Forms

When choosing an eSignature provider for completing and sharing charge forms, compare starting price, trial availability, bulk send, audit trail, HIPAA support, and envelope or session limits.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions About the Discrimination Charge Form

Answers to common questions about timing, e-signatures, agency selection, and supporting documents for a discrimination charge.


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