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<!DOCTYPE html>
<html lang="en">
<head>
<title>OFCCP Complaint Form English</title>
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META
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</head>
<!------------------------------------
COMCOMPLAINT FORM
------------------------------------->
<body OnKeyPress="return disableKeyPress(event)" onload="check_date_required('Print_Signature_Date')">
<div class="scrn-rdr">
<a href="#maincontent">Skip to Main Content</a>
</div>
<div class="form_center">
<!------------------------------------
TOP
------------------------------------->
<div class="top-1-left">
<a style="float: left;" href="https://www.dol.gov">
<img src="https://raw.githubusercontent.com/GSA/logo/master/labor.png" align="top" width="45" border="0" alt="United States Department of Labor" title="United States Department of Labor">
</a>
<a style="float: left;" href="https://www.dol.gov/ofccp/aboutof.html">
<img src="https://www.dol.gov/sites/default/files/slide47.jpg" align="top" width="155" border="0" alt="Office of Federal Contract Compliance Programs" title="Office of Federal Contract Compliance Programs">
</a>
</div>
<div class="top-1-right">
<h1 class="title_top" >Complaint Involving Employment Discrimination by a Federal Contractor or Subcontractor</h1>
</div>
<div class="top-link">
<form name="myform2" action="complaint_submission.asp" method="POST">
<input type="hidden" name="Form_Language" id="Form_Language" value="English">
<input type="hidden" name="Instructions" id="Instructions" value="Show">
<div class="read_instructions" id="read_instructions">
<a href="javascript:instructions();">Please read the instructions before completing this form.</a>
</div>
</form>
</div>
<div class="Form_Main">
<form name="myform" id="myform" action="complaint_submission.asp" method="POST" onsubmit="return validateForm();">
<input type="hidden" name="Instructions" id="Instructions" value="NoShow">
<input type="hidden" name="Form_Language" id="Form_Language" value="English">
<div class="top-2-left" >
<p>OMB: 1250-0002</p>
<p>Expires: 5/31/2020</p>
</div>
<div class="top-2-right" >
<input class="button_exec" id="button_exec" type="button" onclick="return clear_form()" value="Reset Form">
<input class="button_exec" id="button_exec" type="button" onclick="return print_form()" value="Print Form">
<input class="button_exec" id="button_exec" type="button" onclick="return validateForm()" value="Submit">
</div>
<!------------------------------------
SECTION 1
------------------------------------->
<div class="column-left-1">
<h2 id="maincontent" tabindex="-1">How can we reach you?</h2>
</div>
<div class="column-right-1">
<div class='stack'>
<label for="Fullname1">Name (First, Middle, Last):</label>
<input size="50" type="text" name="Fullname1" id="Fullname1" onchange="return check_name_required('Fullname1')" maxlength=50>
</div>
<div class='stack'>
<label for="Address1">Street Address:</label>
<input size= "50" type="text" name="Address1" id="Address1" onchange="return check_address_required('Address1')" maxlength=50>
</div>
<div class='stack4'>
<label for="City1">City:</label>
<input size= "50" type="text" name="City1" id="City1" onchange="return check_city_name_required('City1')" maxlength=50>
</div>
<div class='sameline'>
<label for="state1">State:</label>
<select style="width: 125px;" name="state1" id="state1" size="1" onchange="return check_state_required('state1')">
<option value="">Select a state....</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="GU">Guam</option>
<option value="PR">Puerto Rico</option>
<option value="VI">Virgin Islands</option>
</select>
</div>
<div class='sameline_zipcode'>
<label for="Zipcode1">Zip Code:</label>
<input size= "10" type="text" name="Zipcode1" id="Zipcode1" onchange="return check_zipcode('Zipcode1')" maxlength=10>
</div>
<div class='stack24'>
<label for="Telephone1">Telephone Number:</label>
<input size= "15" type="text" name="Telephone1" id="Telephone1" onchange="return check_telephone_not_required2('Telephone1')" maxlength=15>
</div>
<div class='sameline'>
<input value="1" id="Home1" name="Telephone_type1" type="checkbox" onkeypress="return button_on_or_off2(event,'Home1')" >
<label for="Home1">Home</label>
<input value="2" id="Work1" name="Telephone_type1" type="checkbox" onkeypress="return button_on_or_off2(event,'Work1')" >
<label for="Work1">Work</label>
<input value="3" id="Cell1" name="Telephone_type1" type="checkbox" onkeypress="return button_on_or_off2(event,'Cell1')" >
<label for="Cell1">Cell</label>
</div>
<div class='stack'>
<label for="Email1">E-mail: </label>
<input type="text" name="Email1" id="Email1" size=60 onchange="return check_email('Email1')" maxlength=60>
</div>
<div class='stack2'>
<p class="spcdwnup">Have you filed these allegations of employment discrimination with another federal or local agency?</p>
</div>
<div class='stack'>
<input value="1" id="Allegations_Yes" name="Allegations1" type="checkbox" onkeypress="return button_on_or_off(event,'Allegations_Yes','Allegations_No')" onclick="return mouse_on_or_off('Allegations_Yes','Allegations_No')">
<label for="Allegations_Yes">Yes</label>
<input value="2" id="Allegations_No" name="Allegations1" type="checkbox" onkeypress="return button_on_or_off(event,'Allegations_No','Allegations_Yes')" onclick="return mouse_on_or_off('Allegations_No','Allegations_Yes')">
<label for="Allegations_No">No</label>
</div>
<div class='stack24'>
<label for="Agency_Name1">If yes, which agency:</label>
<input size= "40" type="text" name="Agency_Name1" id="Agency_Name1" onchange="return check_agency_name('Agency_Name1')" maxlength=50>
</div>
<div class='sameline'>
<label for="Agency_POC1">Contact Name:</label>
<input size="20" type="text" name="Agency_POC1" id="Agency_POC1" onchange="return check_allegations_contact_name('Agency_POC1')" maxlength=30>
</div>
<div class='sameline'>
<label for="Agency_Telephone1">Phone Number:</label>
<input size="15" type="text" name="Agency_Telephone1" id="Agency_Telephone1" onchange="return check_agency_telephone('Agency_Telephone1')" maxlength=15>
</div>
</div>
<!------------------------------------
SECTION 2
------------------------------------->
<div class="column-left-2" >
<h2>Who can we contact if we cannot reach you?</h2>
</div>
<div class="column-right-2" >
<div class='stack'>
<label for="Fullname2">Name (First, Middle, Last):</label>
<input size= "50" type="text" name="Fullname2" id="Fullname2" onchange="return check_contact_name('Fullname2')" maxlength=50>
</div>
<div class='stack'>
<label for="Address2">Street Address:</label>
<input size= "50" type="text" name="Address2" id="Address2" onchange="return check_contact_address('Address2')" maxlength=50>
</div>
<div class='stack4'>
<label for="City2">City:</label>
<input bgcolor="#3CBC8D" size= "50" type="text" name="City2" id="City2" onchange="return check_contact_city_name('City2')" maxlength=50>
</div>
<div class='sameline'>
<label for="state2">State:</label>
<select style="width: 125px;" name="state2" id="state2" size="1" >
<option value="">Select a state....</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="GU">Guam</option>
<option value="PR">Puerto Rico</option>
<option value="VI">Virgin Islands</option>
</select>
</div>
<div class='sameline_zipcode'>
<label for="Zipcode2">Zip Code:</label>
<input size= "10" type="text" name="Zipcode2" id="Zipcode2" onchange="return check_contact_zipcode('Zipcode2')" maxlength=10>
</div>
<div class='stack24'>
<label for="Telephone2">Telephone Number:</label>
<input size= "12" type="text" name="Telephone2" id="Telephone2" onchange="check_contact_telephone('Telephone2')" maxlength=15>
</div>
<div class='sameline'>
<input value="1" id="Home2" name="Telephone_type2" type="checkbox" onkeypress="return button_on_or_off2(event,'Home2')" >
<label for="Home2">Home</label>
<input value="2" id="Work2" name="Telephone_type2" type="checkbox" onkeypress="return button_on_or_off2(event,'Work2')" >
<label for="Work2">Work</label>
<input value="3" id="Cell2" name="Telephone_type2" type="checkbox" onkeypress="return button_on_or_off2(event,'Cell2')" >
<label for="Cell2">Cell</label>
</div>
<div class='stack'>
<label for="Email2">E-mail: </label>
<input type="text" id="Email2" name="Email2" size=60 onchange="return check_contact_email('Email2')" maxlength=60>
</div>
</div>
<!------------------------------------
SECTION 3
------------------------------------->
<div class="column-left-3" id="column-left-3">
<h2>What is the name of the employer that you believe discriminated or retaliated against you?</h2>
</div>
<div class="column-right-3" id="column-right-3">
<div class='stack'>
<label for="Fullname3">Company Name:</label>
<input size= "50" type="text" name="Fullname3" id="Fullname3" onchange="return check_company_name_required('Fullname3')" maxlength=50>
</div>
<div class='stack'>
<label for="Address3">Street Address:</label>
<input size= "50" type="text" name="Address3" id="Address3" onchange="return check_company_address_required('Address3')" maxlength=50>
</div>
<div class='stack4'>
<label for="City3">City:</label>
<input size= "50" type="text" name="City3" id="City3" onchange="return check_company_city_name_required('City3')" maxlength=50>
</div>
<div class='sameline'>
<label for="state3">State:</label>
<select style="width: 125px;" name="state3" id="state3" size="1" >
<option value="">Select a state....</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="GU">Guam</option>
<option value="PR">Puerto Rico</option>
<option value="VI">Virgin Islands</option>
</select>
</div>
<div class='sameline_zipcode'>
<label for="Zipcode3">Zip Code:</label>
<input size= "10" type="text" name="Zipcode3" id="Zipcode3" onchange="return check_company_zipcode('Zipcode3')" maxlength=10>
</div>
<div class='stack24'>
<label for="Telephone3">Telephone Number:</label>
<input size= "15" type="text" name="Telephone3" id="Telephone3" onchange="return check_company_telephone('Telephone3')" maxlength=15>
</div>
<div class='stack2'>
<label for="Narrative5">Give the date(s) and times you believe you were discriminated against:</label>
<textarea class="nar5" rows="1" name="Narrative5" id="Narrative5" cols="60" onchange="return check_company_textarea_required('Narrative5')" ></textarea>
</div>
</div>
<!-----------------
Section 4
------------------>
<div class="column-left-4">
<h2>Why do you believe your employer discriminated or retaliated against you?</h2>
</div>
<div class="column-right-4">
<!-----------------
Column 1
------------------>
<div class="sec4-col1">
<div class="spcdwn5">
<input value='1' id='Race40' name='Race40' type='checkbox' onkeypress="return button_on_or_off2(event,'Race40')">
<label for="Race40"><b>Race</b></label>
</div>
<div class="spcdwn30">
<p class="indent">
<input value="1" id="Race41" name="Race41" type="checkbox" onkeypress="return button_on_or_off2(event,'Race41')">
<label class="basic2" for="Race41">American Indian or Alaska Native</label>
</p>
</div>
<div class="spcdwn20">
<p class="indent">
<label class="basic2" for="Race4_Tribal_Affiliation4">Indicate Tribal Affiliation:</label>
<p class="indent2">
<input size= "10" type="text" name="Race4_Tribal_Affiliation4" id="Race4_Tribal_Affiliation4" maxlength=50>
</p>
</p>
</div>
<div class="spcdwn5">
<p class="indent">
<input value='1' id='Race42' name='Race42' type='checkbox' onkeypress="return button_on_or_off2(event,'Race42')">
<label class="basic2" for="Race42">Asian</label>
</p>
</div>
<div class="spcdwn5">
<p class="indent">
<input value='1' id='Race43' name='Race43' type='checkbox' onkeypress="return button_on_or_off2(event,'Race43')">
<label class="basic2" for="Race43">Black or African American</label>
</p>
</div>
<div class="offset01">
<p class="indent">
<input value='1' id='Race44' name='Race44' type='checkbox' onkeypress="return button_on_or_off2(event,'Race44')">
<label class="basic2" for="Race44">Native Hawaiian or Other Pacific Islander</label>
</p>
</div>
<div class="spcdwn5">
<p class="indent">
<input value='1' id='Race45' name='Race45' type='checkbox' onkeypress="return button_on_or_off2(event,'Race45')">
<label class="basic2" for="Race45">White</label>
</p>
</div>
</div>
<!-----------------
Column 2
------------------>
<div class="sec4-col2">
<div class="spcdwn5">
<input value="1" id="National_Origin41" name="National_Origin41" type="checkbox" onkeypress="return button_on_or_off2(event,'National_Origin41')">
<label class="basic" for="National_Origin41"><b>National Origin</b></label>
</div>
<div class="spcdwn10">
<p class="indent">
<input value="1" id="National_Origin411" name="National_Origin411" type="checkbox" onkeypress="return button_on_or_off2(event,'National_Origin411')">
<label class="basic2" for="National_Origin411">Hispanic or Latino</label>
</p>
</div>
<div class="spcdwn30">
<p class="indent">
<input value="1" id="National_Origin412" name="National_Origin412" type="checkbox" onkeypress="return button_on_or_off2(event,'National_Origin412')">
<label class="basic2" for="National_Origin412">Other</label>
</p>
</div>
<div class="field">
<input value="1" id="Color4" name="Color4" type="checkbox" onkeypress="return button_on_or_off2(event,'Color4')">
<label class="basic" for="Color4"><b>Color</b></label>
</div>
<div class="field">
<input value="1" id="Religion4" name="Religion4" type="checkbox" onkeypress="return button_on_or_off2(event,'Religion4')">
<label class="basic" for="Religion4"><b>Religion</b></label>
</div>
<div class="field">
<input value="1" id="Sex4" name="Sex4" type="checkbox" onkeypress="return button_on_or_off2(event,'Sex4')">
<label class="basic" for="Sex4"><b>Sex</b></label>
</div>
</div>
<!-----------------
Column 3
------------------>
<div class="sec4-col3">
<div class="spcdwn5">
<input value="1" id="Sexual_Orientation4" name="Sexual_Orientation4" type="checkbox" onkeypress="return button_on_or_off2(event,'Sexual_Orientation4')">
<label class="basic" for="Sexual_Orientation4"><b>Sexual Orientation</b></label>
</div>
<div class="field">
<input value="1" id="Gender_Identity4" name="Gender_Identity4" type="checkbox" onkeypress="return button_on_or_off2(event,'Gender_Identity4')">
<label class="basic" for="Gender_Identity4"><b>Gender Identity</b></label>
</div>
<div class="field">
<input value="1" id="Inquiring_About_Pay4" name="Inquiring_About_Pay4" type="checkbox" onkeypress="return button_on_or_off2(event,'Inquiring_About_Pay4')">
<label class="basic" for="Inquiring_About_Pay4"><b>Inquiring About Pay</b></label>
</div>
<div class="field">
<input value="1" id="Discussing_Pay4" name="Discussing_Pay4" type="checkbox" onkeypress="return button_on_or_off2(event,'Discussing_Pay4')">
<label class="basic" for="Discussing_Pay4"><b>Discussing Pay</b></label>
</div>
<div class="field">
<input value="1" id="Disclosing_Pay4" name="Disclosing_Pay4" type="checkbox" onkeypress="return button_on_or_off2(event,'Disclosing_Pay4')">
<label class="basic" for="Disclosing_Pay4"><b>Disclosing Pay</b></label>
</div>
</div>
<!-----------------
Column 4
------------------>
<div class="sec4-col4">
<div class="offset02">
<input value="1" id="Protected_Veteran_Status4" name="Protected_Veteran_Status4" type="checkbox" onkeypress="return button_on_or_off2(event,'Protected_Veteran_Status4')">
<label class="basic" for="Protected_Veteran_Status4"><b>Protected Veteran Status</b></label>
</div>
<div class="spcdwn5">
<input value="1" id="Disability4" name="Disability4" type="checkbox" onkeypress="return button_on_or_off2(event,'Disability4')">
<label class="basic" for="Disability4"><b>Disability</b></label>
</div>
<div class="field">
<input value="1" id="Retaliation4" name="Retaliation4" type="checkbox" onkeypress="return button_on_or_off2(event,'Retaliation4')">
<label class="basic" for="Retaliation4"><b>Retaliation</b></label>
</div>
</div>
</div>
<!------------------------------------
SECTION 5
------------------------------------->
<div class="column-5">
<h2>How did you learn that you could file a complaint with OFCCP?</h2>
<div class="field_learn">
<input value="1" id="Complaint51" name="Complaint51" type="checkbox" onkeypress="return button_on_or_off2(event,'Complaint51')" >
<label for="Complaint51">Internet</label>
</div>
<div class="field_learn">
<input value="1" id="Complaint52" name="Complaint52" type="checkbox" onkeypress="return button_on_or_off2(event,'Complaint52')" >
<label for="Complaint52">Poster</label>
</div>
<div class="field_learn">
<input value="1" id="Complaint53" name="Complaint53" type="checkbox" onkeypress="return button_on_or_off2(event,'Complaint53')" >
<label for="Complaint53">Community Organization</label>
</div>
<div class="field_learn">
<input value="1" id="Complaint54" name="Complaint54" type="checkbox" onkeypress="return button_on_or_off2(event,'Complaint54')" >
<label for="Complaint54">OFCCP Meeting/Event</label>
</div>
<div class="field_learn">
<input value="1" id="Complaint55" name="Complaint55" type="checkbox" onkeypress="return button_on_or_off2(event,'Complaint55')" >
<label for="Complaint55">Brochure</label>
</div>
<div class="field_learn">
<input value="1" id="Complaint56" name="Complaint56" type="checkbox" onclick="return button_on_or_off2(event,'Complaint56')" onkeypress="return button_on_or_off2(event,'Complaint56')" >
<label for="Complaint56">Other</label>
</div>
</div>
<!------------------------------------
SECTION 6
------------------------------------->
<div class="column-6">
<h2>Your Complaint:</h2>
<p class="spcdwnup"><b>Please describe below what you think the employer did or didn't do that you believe caused discrimination or retaliation, including:</b></p>
<div class="stack">
<ol>
<li>What actions the employer took against you.</li>
<li>Why you believe those actions were based on your: race; color; religion; sex; sexual orientation; gender identity; national origin; disability; veteran status; and/or inquiries about, discussions, or disclosures of your pay or the pay of others; and/or in retaliation for filing a complaint, participating in discrimination proceedings, opposing unlawful discrimination, or exercising any other rights protected by OFCCP.</li>
<li>When the employer actions happened, where they happened, and who was involved.</li>
<li>What harm, if any, you or others suffered because of the alleged discrimination or retaliation.</li>
<li>What explanation, if any, your employer or people representing your employer offered for their actions.</li>
<li>Who was in the same or similar situation as you and how they were treated. Include information such as the race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected status of these individuals, if known.</li>
<li>What information you have about federal contracts the company that you worked for had at the time of the discrimination or retaliation you describe in this complaint.</li>
</ol>
</div>
<div class="stack_nar6">
<label for="Narrative6" class="scrn-rdr">Notes</label>
<textarea class="nar6" rows="4" name="Narrative6" id="Narrative6" cols="60" onchange="return check_textarea_required('Narrative6')" ></textarea>
</div>
</div>
<!------------------------------------
SECTION 7
------------------------------------->
<div class="column-left-7">
<h2>Do you think the discrimination includes or affects others?</h2>
</div>
<div class="column-right-7">
<p class="spcdwn">Do you believe other employees or applicants were treated the same way as you described above? </p>
<div class="sameline">
<input value="1" id="Treated5" name="Treated5" type="checkbox" onclick="return mouse_on_or_off('Treated5','Treated6')" onkeypress="return button_on_or_off(event,'Treated5','Treated6')">
<label for="Treated5">Yes</label>
<input value="2" id="Treated6" name="Treated5" type="checkbox" onclick="return mouse_on_or_off('Treated6','Treated5')" onkeypress="return button_on_or_off(event,'Treated6','Treated5')">
<label for="Treated6">No</label>
</div>
</div>
<!------------------------------------
SECTION 8
------------------------------------->
<div class="column-left-8" >
<h2>Do you have an attorney or other representative?</h2>
</div>
<div class="column-right-8" >
<p class="spcdwn">If you are represented by an attorney, or another person, or an organization, please provide their contact information below.</p>
<div class='stack'>
<label for="Fullname21">Name (First, Middle, Last):</label>
<input size= "50" type="text" name="Fullname21" id="Fullname21" onchange="return check_attorney_name('Fullname21')" maxlength=50>
</div>
<div class='stack'>
<label for="Address21">Street Address:</label>
<input size= "50" type="text" name="Address21" id="Address21" onchange="return check_attorney_address('Address21')" maxlength=50>
</div>
<div class='stack4'>
<label for="City21">City:</label>
<input size= "50" type="text" name="City21" id="City21" onchange="return check_attorney_city_name('City21')" maxlength=50>
</div>
<div class='sameline'>
<label for="state21">State:</label>
<select style="width: 125px;" name="state21" id="state21" size="1" >
<option value="">Select a state....</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="GU">Guam</option>
<option value="PR">Puerto Rico</option>
<option value="VI">Virgin Islands</option>
</select>
</div>
<div class='sameline_zipcode'>
<label for="Zipcode21">Zip Code:</label>
<input size= "10" type="text" name="Zipcode21" id="Zipcode21" onchange="return check_attorney_zipcode('Zipcode21')" maxlength=10>
</div>
<div class='stack24'>
<label for="Telephone21">Telephone Number:</label>
<input size= "15" type="text" name="Telephone21" id="Telephone21" onchange="check_attorney_telephone('Telephone21')" maxlength=15>
</div>
<div class='stack'>
<label for="Email21">E-mail:</label>
<input type="text" size=60 onchange="return check_attorney_email('Email21')" name="Email21" id="Email21" maxlength=60>
</div>
<div class='stack'>
<p class="spcdwnup" >Who should we contact if we need more information about your description of what occurred?</p>
</div>
<div class='sameline'>
<input value="1" id="Attorney5_You" name="Attorney5" type="checkbox" onkeypress="return button_on_or_off(event,'Attorney5_You','Attorney6_You')" onclick="return mouse_on_or_off('Attorney5_You','Attorney6_You')">
<label for="Attorney5_You">You</label>
<input value="2" id="Attorney6_You" name="Attorney5" type="checkbox" onkeypress="return button_on_or_off(event,'Attorney6_You','Attorney5_You')" onclick="return mouse_on_or_off('Attorney6_You','Attorney5_You')">
<label for="Attorney6_You">Your Representative</label>
</div>
</div>
<!------------------------------------
SECTION 9
------------------------------------->
<div class="column-left-9">
<h2>Signature and Verification</h2>
</div>
<div class="column-right-9">
<p class="spcdwn">I declare under penalty of perjury that the information given above is true and correct to the best of my knowledge or belief. A willful false statement is punishable by law.</p>
<p class="spcdwn">I hereby authorize the release of any medical information needed for this investigation.</p>
<div class="sameline">
<label for="Print_Signature">Signature of Complainant:</label>
<input size= "20" type="text" name="Print_Signature" id="Print_Signature" onchange="check_signature_required('Print_Signature')" maxlength=20>
</div>
<div class="sameline">
<label for="Print_Signature_Date">Date:</label>
<input size= "20" type="text" name="Print_Signature_Date" id="Print_Signature_Date" onfocus="check_date_required('Print_Signature_Date')">
</div>
</div>
<!------------------------------------
Foot
------------------------------------->
<div class="column-span-revised">
<p class="title_bottom">Form CC-4 (Revised 5/2017)</p>
</div>
<!------------------------------------
Submit
------------------------------------->
<div class="column-span-submit">
<button class="right" onclick="return validateForm()">Submit</button>
</div>
</form>
</div>
</div>
</body>
</html>