1. You May File A Charge

You have contacted the Kansas Human Rights Commission to seek help concerning possible discrimination in employment.  We will ask you questions about what happened to you, about how others were treated, about dates, the size of the employer, and other matters.  What you tell us is very IMPORTANT so please be specific in your answers.

First, we will have to establish whether we believe that the law permits us to work on your problem; that is, we must try to find out whether we have JURISDICTION (authority) under the law.  If it is clear, based upon what you tell us, that we DO NOT have jurisdiction, we may not be able to accept and investigate your complaint, and we will so inform you.

If you are under 18 years of age, a parent or guardian may file for you.

If you have recently completed this on-line questionnaire and have not yet received your drafted complaint, please contact our Intake Unit at (785) 296-3206 or TDD (785) 296-0245 to inquire about the status.  Please do not complete this questionnaire again if you do not have any new allegations or new incidents to report as it delays drafting your complaint.

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* 1. Have you read You May File A Charge?

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* 2. Contact Information

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* 3. Contact Information Continued

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* 4. Mr./Ms.

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* 5. I prefer to be contacted by: (Choose as many as you wish.)

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* 6. I can best be contacted:

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* 7. Employer Information--Give the full name of the employer that you feel discriminated against you.  It is extremely important that the address is accurate.  An incorrect address may result in your complaint not being processed.  You may be asked to provide verification of the name by either a copy of your pay stub, business card or letterhead.

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* 8. Are you now employed by the company, agency, etc.?

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* 9. Were you employed at a temp agency and placed at this job site?

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* 10. Date Hired (Skip if not applicable.)

Date 

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* 11. Last Date Worked (Skip if currently employed.)

Date

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* 12. Present or Last Job Title (Or Job Title applied for)

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* 13. I was subjected to the following adverse actions due to discrimination/harassment. (Choose as many as applicable.)

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* 14. I was harassed by: (Choose as many as applicable.) (Skip this question if it is not applicable.)

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* 15. My alleged harasser(s) are: (Check as many as applicable.) (Skip this question if it is not applicable.)

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