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HR Charge of Discrimination Form

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HR CHARGE OF DISCRIMINATION FORM

Personal Information

Phone:

Email:

Email Phone U.S. Mail

Position Information

Reporting Manager:

Work Location:

Date first employed in current position:

Active On Leave Terminated

Allegation Details

Type(s) of discrimination alleged (check all that apply):

Race Color National Origin Sex (including pregnancy) Religion
Age (40+) Disability Genetic Information Other:

Yes No

Relief Requested

What remedy or action are you seeking? (Check all that apply and provide details where requested)

Reinstatement Promotion Back pay / Compensation Training / Policy Change Other:

Employment History (For context)

Provide your two most recent prior employers (or current employer followed by previous employer).

Title:

Dates Employed: From To

Title:

Dates Employed: From To

Education

Graduation or completion date:

Professional References

Provide three professional references who can speak to your qualifications and relevant work history.

Legal Notices and Acknowledgements

Equal Employment Opportunity: The employer maintains a policy prohibiting discrimination and harassment on the basis of protected characteristics. This charge will be investigated in accordance with policy and applicable law. Substantiated violations will result in corrective action up to and including termination.

Retaliation Prohibited: Retaliation against any individual for filing a charge, participating in an investigation, or requesting accommodation is strictly prohibited. If you believe you have been retaliated against, report it immediately.

Confidentiality and Disclosure: The employer will make reasonable efforts to protect confidentiality, but absolute confidentiality cannot be guaranteed. Information will be disclosed on a need-to-know basis for investigation, remedial action, or as required by law.

Authorization to Investigate and Contact: By submitting this charge, I authorize the employer to conduct a full investigation, to interview current and former employees, and to obtain relevant records, including personnel and employment records, and to contact prior employers as necessary to investigate allegations.

At-Will Employment Statement: Nothing in this form alters the at-will employment relationship between the employee and the employer unless set forth in a separate, written agreement signed by authorized representatives of the employer.

Certification and Authorization

I certify that the information provided in this Charge of Discrimination Form is true and complete to the best of my knowledge and belief. I understand that knowingly providing false information may result in disciplinary action, up to and including termination. I authorize the employer to conduct an investigation, to obtain personnel records, and to contact listed references and prior employers for relevant information.

I understand that submission of this charge initiates an internal review. The internal review process may include interviews, review of documents, and recommended corrective action. I acknowledge that I will be informed of the outcome to the extent permitted by privacy requirements and law.

Complainant Printed Name:

Signature:

Date Signed:

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What the HR Charge of Discrimination Form Is and when it’s used

The HR Charge of Discrimination Form documents an employee or applicant allegation that they were treated unfairly because of a protected characteristic (race, sex, age, disability, religion, national origin, or other protected class). Employers use the form to capture the complainant’s identity, a clear description of the alleged acts, dates, witnesses, and requested remedies. The form creates a consistent intake record for internal investigations, establishes a timeline for compliance and corrective action, and can support subsequent filings with the EEOC or state civil rights agency if the internal process does not resolve the matter.

Why consistent intake with a formal charge form matters

A structured HR Charge of Discrimination Form reduces ambiguity, preserves key facts, and supports timely investigations. It helps HR apply policy consistently, document corrective steps, and produce a defensible record if a charge moves to the EEOC or a state agency.

Why consistent intake with a formal charge form matters

Who completes and relies on the HR Charge of Discrimination Form

The form is used across HR, employee relations, and by complainants who want an official record of an allegation before escalation.

  • HR or Employee Relations staff: Intake, triage, and investigation documentation for consistency and policy compliance.
  • Complainant or affected employee: Provides their account, dates, witnesses, and desired remedies in writing for the record.
  • Legal or compliance teams: Use the form to assess risk, determine whether to report to EEOC or state agency.

Proper routing and access control ensure the right staff handle intake, investigation, and retention without exposing sensitive details.

Primary roles who sign or approve the form

HR Manager

HR Managers review submissions, assign investigatory staff, and ensure documentation meets internal policy requirements and legal standards for escalation.

Complainant

The employee or applicant provides a signed account, lists witnesses and dates, and indicates the remedies sought; their signature establishes attribution and intent.

Security and compliance essentials for handling charges

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
Access controls: Role-based access and audit logging
Audit trail: Timestamps, IP, action history
HIPAA considerations: BAA required if PHI is included
eSignature law: ESIGN and UETA compliance
Retention policy: Secure storage, controlled deletion

Step-by-step: completing the HR Charge of Discrimination Form

Follow these ordered steps to collect complete, actionable information and preserve legal integrity during intake and investigation.

  • 01
    Gather complainant details: Enter legal name, contact, job title, and employee ID.
  • 02
    Record incident specifics: Include dates, locations, alleged conduct, and actions.
  • 03
    List witnesses and evidence: Provide names, contacts, and attachments like emails.
  • 04
    Sign and route: Complainant signs; route to HR and legal as required.

Typical intake and resolution flow for an HR discrimination charge

A clear workflow reduces delays and preserves evidence; use consistent routing and documented steps for each case.

  • Intake: Complainant submits the form; HR logs the report.
  • Assessment: HR screens for severity and interim measures.
  • Investigation: Collect statements, documents, and witness interviews.
  • Resolution: Implement corrective action and document closure.

Configuring an online HR Charge form and workflow

Recommended digital settings for accuracy, authentication, and compliant routing when moving the form online.

Field Configuration
Authentication Require email verification; consider SMS code for sensitive cases
Conditional fields Show witness fields only when witness present
Attachments Allow file uploads (emails, screenshots) up to configured size
Routing Auto-route to HR and legal based on severity flag

Technical delivery and integration considerations

Choose a platform that supports secure uploads, audit trails, and integration with HRIS and case management systems.

  • File formats: PDF and DOCX accepted
  • Integrations: Connect to HRIS, cloud storage, and case tools
  • Authentication options: Email, SMS, or stronger MFA

Ensure the platform supports retention controls and role-based access to meet legal and privacy obligations.

Key deadlines and processing expectations

Track internal and external time limits to preserve rights and meet investigatory obligations; timelines vary by jurisdiction and filing route.

Internal reporting:

Report promptly; many employers set 24–72 hour intake targets

EEOC filing window:

Typically 180 days; 300 days if state law applies

State agency deadlines:

Varies—some states mirror EEOC timing

Investigation timing:

Complete fact-finding promptly; timeline depends on complexity

Retention start:

Record retention begins at intake date

Consequences of incomplete or incorrect charge documentation

Missed filing window: May forfeit right to pursue agency claims
Incomplete facts: Weakens investigatory outcomes and defenses
Privacy breaches: Cause regulatory fines and reputational harm
Retaliation exposure: Poor handling can trigger separate claims
Evidentiary gaps: Loss of witness contact details harms proof
Improper disclosures: May violate confidentiality or discovery rules

Common preparation mistakes to avoid

  • Vague incident descriptions without dates or quotes hinder fact-finding and prolong investigations, increasing risk for all parties involved.
  • Failing to collect contact information for witnesses or forgetting to attach relevant documents such as emails can result in incomplete evidence.
  • Using informal language or conclusions (e.g., 'hostile person') instead of factual accounts can weaken the complaint in review or external filing.
  • Not securing the form and limiting access increases privacy risk and may lead to improper disclosures during the process.

eSignature vendor pricing and capability snapshot for charge processing

Compare common vendor entry-level pricing and select capabilities relevant to secure HR intake and eSubmission; signNow is listed first per vendor convention.

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 by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Real-world scenarios illustrating when to use the form

Two anonymized, representative examples show typical intake and outcomes to clarify practical use and documentation needs.

Internal harassment allegation

A staff member reported repeated derogatory comments by a supervisor in the workplace.

  • HR logged dates, collected witness statements, and temporarily reassigned parties.
  • The standardized form preserved key facts, supported corrective action, and produced a clear record for the state agency when the complainant later filed externally.

Disability accommodation denial

An applicant alleged failure to accommodate during hiring.

  • The form captured requested accommodation, recruiter responses, and timeline.
  • Documentation enabled HR to assess process gaps, remedy procedures, and demonstrate the employer’s subsequent policy updates.

Practical tips to improve accuracy and defensibility

Apply consistent standards to intake, restrict access to sensitive fields, and preserve records to support fair investigations and potential agency review.

Use precise, chronological descriptions
Record events in order with dates and direct quotes where available; avoid conclusions and maintain factual language to strengthen investigatory clarity and reduce ambiguity during review or external proceedings.
Limit access and track changes
Restrict who can view and edit the form using role-based permissions and capture an immutable audit trail to show who accessed or modified the record and when.
Collect corroborating evidence at intake
Request emails, screenshots, and witness contacts up front; immediate collection reduces loss of evidence and shortens investigation timeframes while improving outcome reliability.
Review retention and legal holds
Preserve records subject to litigation or regulatory inquiry; ensure retention schedules align with I-9, HIPAA, and state-specific rules to avoid inadvertent destruction.

Frequently asked questions about the HR Charge of Discrimination Form

Answers to common questions about filing, eSigning, deadlines, corrections, and supporting documentation for internal intake and external filing.


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