NCESC Appeal question

Employment Discrimination

I am a:

 Employee
 Former Employee
 Job Applicant
 Independent Contractor
 Employer
 Other:  

I believe I am being discriminated against based on my:

 Age. My age is: 
 Disability. My disability is: 
 Gender. My gender is: 
 National origin. My national origin is: 
 Race. My race is: 
 Religion. My religion is: 
 Sexual orientation. My sexual orientation is: 
 Other:  

The discrimination occurred at this stage of the employment:

 Hiring
 Firing
 Layoffs
 Compensation
 Promotion or transfer
 Normal work
 Other:  

What date or time period did the discrimination occur?:

Are there any witnesses and/or evidence to support your claim?:

 Yes. Explain: 
 No 

Date of hire:

  

Occupation / job title:

Gross annual income:

 $25,000 or less
 $25,001-$50,000
 $50,001-$75,000
 $75,001-$100,000
 $100,001-$125,000
 $125,000+ 

Is the employee still working for the employer:

 Yes
 No. Last day of employment was:  
 Employment has not yet begun 

The employer is a:

 Sole proprietorship (mom and pop)
 Partnership
 Franchise
 Privately held corporation
 Public corporation
 Non-profit
 Professional organization (law, accounting, architecture, etc.)
 Government agency
 Other: 
 I don't know 

The employer is involved in this type of industry:

 High technology
 Retail
 Professional (law, accounting, architecture, etc.)
 Construction
 Education
 Government
 Manufacturing
 Transportation
 Health Care
 Restaurant
 Other:  

The employer has the following number of employees:

 1-15
 16-50
 51-100
 101+ 

What type of employment contract do you have:

 At-will employment - either party can terminate
 Written contract for a specified period of time
 Oral contract for a specified period of time
 Union contract
 No contract
 I am not sure
 Other:  

A complaint was filed with the:

 Equal Employment Opportunity Commission (EEOC) / federal employment agency on this date:  
 State employment agency on this date:  
 No complaint was filed with a federal or state employment agency 

Wrongful Termination

The job termination was wrongful because:

 It was based on discrimination (such as race, color, religion, national origin, sex or age)
 It was based on other forms of discrimination (such as sexual orientation, physical and mental disabilities, marital status or receiving public funds)
 It was done in retaliation for reporting unsafe working conditions
 There was an employment contract that specified only "good cause" terminations
 There was an employment contract for a specified period of time that had not yet passed
 Other:  

How did you leave the company?:

 Was fired
 Was laid off / reduction in workforce
 Voluntarily resigned
 Forced to resign
 Retired
 Other: