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Immigrant and Employee Rights Section (IER)

IER Charge Form

Instructions for Filling Out This Form

You should complete this charge form by entering the information requested. If a question is not applicable, you should leave it blank. However, fields marked with an asterisk (*) are required. At the bottom of this form, you will need to click the "Next" button. After clicking "Next," you will have to check to see if the information you have entered is correct. To submit the form, you will have to click "This is correct, Submit." If you need to make a correction to the information you have entered, you will need to click "Make a correction," make the needed correction, and then click "Next" again. If the information is correct, you will have to click "This is correct, Submit."

If you would like to submit an electronic charge form in a language other than English, you may click on one of the languages listed above. If IER does not have a charge form in your language, you can send us information about yourself and what happened to you in whatever language you prefer. IER will translate the information that you send us into English. IER can also contact you in your preferred language if IER has any questions for you. Below you will find instructions on how to send IER information by mail, fax, or email.

Filing Supporting Documents

You cannot attach supporting documents directly to this form. If you want to submit other documents, you can do so by using the following instructions. Please only send copies of documents, not originals. When transmitting attachments or documents relating to this form, please include the reference number that will generate once you have submitted the form.

By Email:
If you provide an email address, you will receive a confirmation email once we receive your form. If you would like to attach files or documents to support your form, you may submit them by replying to the confirmation email and attaching the files to your reply message.

By Mail:
You may mail any attachments or documents to support your form to:

Immigrant and Employee Rights Section
Civil Rights Division
US Department of Justice
950 Pennsylvania Avenue, NW (NYA)
Washington, DC 20530

By Fax:
You may also fax attachments or documents to support your form to 202-616-5509.

Section 1: Injured Party Contact Information

Name and Address of the Injured Party (the person who claims to have been the victim of discrimination or retaliation)

MaleFemale









Telephone





YesNo


Section 2: Injured Party’s Citizenship or Immigration Status Information

Citizen
National of the United States
Lawful Permanent Resident
Date residency granted:
NoYes
Date of application:
Asylee
Refugee
Temporary Resident admitted under § 1160(a) or § 1255(a)
(certain individuals eligible to have their status adjusted based on amendments to the INA in the 1980’s)
None of the above, but is authorized to work
Expiration date:
H-1
H-2
F-1/OPT
J-1
B-1
Asylee Applicant
Freely Associated States (FAS)
Temporary Protected Status (TPS)
Other

(for all non-citizens)

(if no alien #)

Section 3: Injured Party’s National Origin and Other Personal Information



What is the Injured Party’s date of birth?
   

Section 4: Type of Discrimination Alleged

What type of discrimination is being alleged?* Check all that apply:

(The Injured Party was discriminated against with respect to hiring, firing, or recruitment or referral for a fee because the Injured Party is from a particular country or part of the world, because of the Injured Party’s ethnicity or accent, or because of limited English ability.)

(The Injured Party was discriminated against with respect to hiring, firing, or recruitment or referral for a fee because the Injured Party is, or is not, a U.S. citizen, or based on the Injured Party’s immigration status.)

(The Injured Party filed a charge of discrimination, complained about discrimination, participated in the investigation or case of another individual’s discrimination claim, or otherwise asserted a right under the anti-discrimination provision, and, as a result, the Injured Party was retaliated against, intimidated, threatened, or coerced.)

(The individual, business or organization refused to accept a valid document, specified the documentation the Injured Party could show, or demanded more or different documents than are required for completing the Employment Eligibility Verification (Form I-9 or E-Verify) because of the Injured Party’s citizenship status or national origin.)

Section 5: Employer Information

Who committed the alleged discriminatory act?









YesNo



Fewer than 4
4-14
15 or more
Don't know/Unable to estimate

Section 6: Date and Place the Discrimination Occurred and the Specifics of the Discrimination Alleged

When did the discrimination occur?

Where did the discrimination occur?




Include whether the Injured Party was fired, laid-off, not hired, delayed start date, asked for additional documents, retaliated against, or other, and describe what happened in detail.

4000 /4000 characters remaining.

Filing Supporting Documents

You cannot attach supporting documents directly to this form. If you want to submit other documents, you can do so by using the following instructions. Please only send copies of documents, not originals. When transmitting attachments or documents relating to this form, please include the reference number that will generate once you have submitted the form.

By Email:
If you provide an email address, you will receive a confirmation email once we receive your form. If you would like to attach files or documents to support your form, you may submit them by replying to the confirmation email and attaching the files to your reply message.

By Mail:
You may mail any attachments or documents to support your form to:

Immigrant and Employee Rights Section
Civil Rights Division
US Department of Justice
950 Pennsylvania Avenue, NW (NYA)
Washington, DC 20530

By Fax:
You may also fax attachments or documents to support your form to 202-616-5509.

Section 7: Charges Filed with Other Federal or State Agencies Based on the Same Facts


NoYes

If yes:








Date Filed

(if known)

(if known)

Section 8: Charging Party Contact Information (Injured Party or person filing charge on the Injured Party’s behalf)


Yes, the same. If yes, skip to #9. No

If no:

MaleFemale














Section 9: Communications with IER


YesNo

If yes:

When?


Telephone hotlineE-mailOutreach event


Section 10: Optional Information

How did you hear of IER? (check all that apply)
 Internet
 IER Outreach
 E-Verify
 SSA No Match
 I-9 Form or Employer Handbook
 Poster/Brochure
 TV
 Radio
 Department of Labor (DOL)
 Equal Employment Opportunity Commission (EEOC)
 State or Local Agency
 United States Citizenship and Immigration Services (USCIS)
 Union/Community Advocacy Group
 Friend/Relative
 Other
The Injured Party is: (check all that apply)
 Hispanic or Latino
 Asian
 Black or African American
 White
 American Indian or Alaska Native
 Native Hawaiian or Other Pacific Islander
 Two or more races

Privacy Act Statement

The authority for requesting this information from the Injured or Charging Party is contained in 8 U.S.C. § 1324b. The information that the Injured or Charging Party provides will be used principally for investigating and processing the charge of prohibited discrimination; however, the information may also be used for other legitimate purposes, as detailed in the Department of Justice’s Federal Register Notice published in the Federal Register at 68 Fed. Reg. 47611 (August 11, 2003) describing the routine uses of the information obtained by the Civil Rights Division. The Injured or Charging Party’s failure to provide the information requested on this form could lead to the charge being dismissed or not being accepted. Knowingly making false statements on this form is punishable under 18 U.S.C. § 1001.

Paperwork Reduction Act Notice

This request is in accordance with the Paperwork Reduction Act of 1995. The information collection is necessary to enable the Department to process and investigate individual charges of discrimination in violation of 8 U.S.C. § 1324b as required by statutory mandate. The use of this collection instrument will facilitate this process by assisting charging parties to identify and provide the information necessary to initiate an investigation.

The estimated average burden associated with this collection is 30 minutes per charging party or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to IER's Special Policy Counsel, USDOJ-CRT-IER, 950 Pennsylvania Avenue, NW-NYA, Washington, DC 20530.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

OMB Number: 1190-0018
Revised date: 02/09/2017

General Information Office of the Assistant Attorney General
 
Leadership
Vanita Gupta
Principal Deputy Assistant Attorney General
Contact
Civil Rights Division
(202) 514-4609
Telephone Device for the Deaf (TTY) (202) 514-0716
 Visit ADA.gov
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