Employment Discrimination Questionnaire
Use this form if you were discriminated against on the job or looking for a job. (For example, if you were fired, demoted, disciplined, transferred, paid less, given lesser benefits or less-desirable working conditions, harassed, or not hired, AND the negative action was based on your race, color, sex, age (40 or over), religion, ancestry, national origin, disability, use of a service animal for a disability, or because you hold a GED rather than a high school diploma.)
This is also the form to use if your employer refuses to make a reasonable accommodation for your disability or religious creed. If you have questions, or are uncertain about whether what happened to you might be employment discrimination, please contact the PHRC regional office serving the county where the discrimination happened.