CC-4 OFCCP Complaint Form

Complaint of Discrimination In Employment
Under Federal Government Contracts
Reset

Print

Submit

U.S. Department of Labor
Employment Standards Administration
Office of Federal Contract Compliance Programs

Instructions: Before completing this form, please read all instructions, including the Privacy Act statement below. Use this OMB No.: 1215-0131
Expires:1-31-08
form to file a complaint of discrimination in employment under any of the OFCCP programs. Note: Persons are not
required to respond to this collection of information unless it displays a currently valid OMB control number.

Privacy Act Notice:
The authority for collecting this information is Executive Order 11246, as amended; Sec. 503 of the Rehabilitation Act of 1973, as
amended; the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212; Title VII of the Civil
Rights Act of 1964, as amended; and/or Title I of the Americans with Disabilities Act of 1990, as amended (ADA). This
information is used to process complaints and conduct investigations of alleged violations of the above Order or Acts. We will
provide a copy of this complaint to the employer against whom it is filed and, when matters alleged are covered by Title VII
and/or the ADA, to the U.S. Equal Employment Opportunity Commission (EEOC). The information collected may be verified with
others who may have knowledge relevant to the complaint. It may be used in settlement negotiations with the employer or in the
course of presenting evidence at a hearing, or may be disclosed to other agencies with jurisdiction over the complaint. Providing
this information is voluntary; however, failure to provide the information will restrict the action that the Department of Labor can
take on your behalf and, for matters covered by Title VII or the ADA, may affect your right to sue under those laws.
Non-Retaliation:OFCCP regulations, and Title VII and/or the ADA where applicable, require an employer to take all necessary steps to assure
that there is no retaliation against any person who files a complaint or assists in its investigation. This includes any intimidation, threat, coercion
or discrimination. Please notify OFCCP immediately if any alleged attempt at retaliation is made.
Prompt Filing : All complaints must be filed within a specified number of days following the latest occurrence of the alleged discrimination. Executive
Order 11246 - 180 days; Rehabilitation and Veterans Acts - 300 days. Exceptions must be approved by the Deputy Assistant Secretary.
Name and address:

Mr.

Ms.

Mrs.

Name and address of company you allege discriminated against you

Miss

Name

Name
Line #1

City

Line #2

State:

Zip

Line #1

City

Line #2

State

Zip

Telephone No.

Telephone No.

Mail this form to Dept. of Labor OFCCP Regional Office:

Give date(s) of the latest occurrence(s) of the alleged discriminatory act(s):

Step 1: Check the box next to the program you are filing under (i.e., Executive Order 11246, as amended; Section 503 of the Rehabilitation Act of 1973,
as amended, or the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212.)
Step 2: Under the program, check what you believe to be the basis for the discrimination against you, such as race, sex or national origin. If you think
that there was more than one basis, more than one basis may be checked. You may also check more than one race/ethnic category.
Executive Order 11246, as amended . This Order covers persons alleging discrimination because of race, color, religion, sex or national origin.
If this is checked, your complaint will be dual-filed as a charge under Title VII of the Civil Rights Act of 1964. I believe I was (or continue to be)
discriminated against because of my:
Bases:

Race

Hispanic or Latino

American Indian or Alaska Native

Color
Not Hispanic or Latino
Asian
Religion
Black or African American
Sex (
)Female (
) Male
Native Hawaiian or Other Pacific Islander
White
National Origin
Other
Section 503 of the Rehabilitation Act of 1973, as amended - This Act covers individuals with a disability, persons with a history of physical or
mental disability, and persons regarded as disabled by the employer. If this is checked, your complaint will be dual-filed as a charge under the
Americans with Disabilities Act.
Basis:

Disability Please check if you are a veteran. [

] Yes [

] No

Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212. This Act covers special disabled veterans,
veterans of the Vietnam Era, and other protected veterans.

1

Form CC-4
Rev. Sep 2004

IF YOUR COMPLAINT IS BASED ON VETERAN STATUS, CHECK THE FOLLOWING APPLICABLE BOX(ES).
I am entitled to disability compensation under laws administered by the Department of Veterans Affairs for a disability rated at 30% or
more; or rated at 10 or 20% and have been officially determined to have a serious employment disability. If you have checked this
box, submit documentation from the Department of Veterans Affairs with this form.
I was discharged or released from active duty for a service connected disability. If you have checked this box, submit medical
information resulting in your discharge or release with this form. (This information is available from your Master Military Record at the
National Personnel Record Center, 9700 Page Blvd., St. Louis, MO 63132.)
I served on active duty for a period of more than 180 days, and was discharged or released with other than a dishonorable discharge,
and the active duty occurred in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or between August 5, 1964,
and May 7, 1975 in all other cases.
I served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.
,ZDVGLVFKDUJHGRUUHOHDVHGIURPDFWLYHGXW\DQGP\GLVFKDUJHRUUHOHDVHGDWHLVQRHDUOLHUWKDQRQH\HDUSULRUWRWRGD\¶VGDte.


Step 3: Check those actions which you believe the employer took or failed
to take because of your race, color, religion, sex, national origin, disability or
veteran status (more than one may be checked):

Issue(s):
Hiring

Promotion

Job Assignment

Accommodation to Disability

Termination

Demotion

Training and Apprenticeship

Sabbath Day Observance

Layoff

Seniority

Segregated Facilities

Intimidation

Recall

Harassment

Retaliation

Other:

Wages

Job Benefits

Pregnancy Leave Policy

FOR EACH ISSUE, EXPLAIN IN YOUR STATEMENT BELOW HOW YOU WERE DISCRIMINATED AGAINST.
1. Do you know any other employees or applicants of your group who were treated in the same way (checked above) you allege you were?
If yes, include their names in your statement below and explain how they were treated.
Yes
No
2. Do you know any other employees or applicants who are NOT of your group who were treated in the same way (checked above) you allege you were?
Yes

No

If yes, include their names in your statement below and explain how they were treated.

THE COMPLAINT
Describe in detail the alleged discriminatory act(s).
PLEASE INCLUDE:
• Why you believe the act(s) was because of your disability, veteran status, race, color, religion, sex or national origin;
• Dates, places, names and titles of persons involved and witnesses, if any;
• What harm, if any, was caused to you or others with whom you work as a result of the alleged discriminatory act(s);
• What explanation, if any, was offered for the act(s) by the employer;
• Any information you may have on federal contracts held by the employer.
If this is a complaint based on disability, describe the disability, your history of disability, or why you think the employer regarded you as disabled.

2

(Type as much information as required into the block above)
3

If you have sought assistance in resolving this complaint from another source (another agency, a lawyer, internal grievance procedure, etc.)
please indicate here and the name of the source, the date you sought assistance, and the result, if any:
Name

Date

Result:

FRIEND OR RELATIVE:
Please notify OFCCP if you change your address or phone number. You may indicate here a person who would know how to reach you if OFCCP is
unable to reach you at your own address or phone.

Name
Line 1

City

Line 2

State

Zip

Relationship
Telephone
FILED ELSEWHERE?

ARE YOU REPRESENTED?

If you have filed this complaint or a similar one elsewhere, please tell us:

If you are represented by an attorney or other person or organization,
please tell us:

Name

Name

Line 1

City

Line 2

State

Zip

Line 1

City

Line 2

State

Contact

Contact

Phone

Phone

Zip

SIGNATURE AND VERIFICATION
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: 18 U.S.C. 1001.) I hereby authorize the release of any medical information needed for the investigation.

Signature of Complainant

Date

Public Burden Statement
We estimate that it will take an average of 1.28 hours to complete this complaint form, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding
these estimates or any other aspect of this complaint form, including suggestions for reducing this burden, send them to the Office of Federal
Contract Compliance Programs Policy Division (1215-0131), 200 Constitution Avenue, N.W., Room C3310, Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
Do not write below this line
The complainant has verified this complaint in my presence. This complaint is not now the basis of an investigation under Executive Order 11246,
as amended; Section 503 of the Rehabilitation Act of 1973, as amended; and/or the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as
amended, 38 U.S.C. 4212.

Name of Investigator

Signature of Investigator

Title

Submit

Reset
4

Print

Date