Small Employer Employment Discrimination Complaint Questionnaire Form

If you suspect you have been discriminated against in employment, you can file a complaint below or call the city of Phoenix Equal Opportunity Department at 602-262-7486/voice or 602-534-1557/TTY.  

Jurisdictional Elements: Business/employer located within the city of Phoenix boundaries

  • The employer has 14 or fewer employees
  • The incident occurred within the past 180 days.
  • For further information visit:


  • Name:*
  • Home Address:
  • City: State: Zip:
  • Work Address:
  • City: State: Zip:
  • Company Name:*
  • Best time to call:
  • Home phone:*
  • Work phone:
  • Cell phone:
  • Pager:
  • E-mail address:
  • Today's date:* (mm/dd/yyyy)
  • If applicable to your complaint of discrimination, what is your:

  • Race
  • National Origin
  • Religion
  • Gender
  • Color
  • Sexual Orientation
  • Marital Status
  • Number of employees locally:*
  • Number of employees nationally:*
  • Please identify potential witnesses by name, title and department. Include address and phone number where known:

    Witness name: Daytime phone:
    Address: Cell/Evening phone:
    Witness name: Daytime phone:
    Address: Cell/Evening phone:

    What happened to you? Please include dates, witnesses and/or comparative employees who were treated differently. How were you discriminated against?

    For example: Were you terminated, not selected for a position, demoted or treated differently in the terms and conditions of your employment?*

    Why do you believe you are being discriminated against? It is a violation of the law to discriminate against, or harass in any aspect of employment for the following reasons: age, genetic information, race, sexual orientation, color, religion, sex, national origin, marital status, disability or gender identity or expression.

    Briefly explain why you think your employment rights were denied because of any of the factors listed above.*

    Who do you believe discriminated against you? Was it your supervisor, a co-worker or subordinate?

  • Name:
  • Title/Position:
  • Address:
  • City:   State:   Zip code:
  • If applicable, what is that person's: 

  • Race
  • National Origin
  • Religion
  • Gender
  • Sexual Orientation
  • Color
  • Marital Status
  • Is the alleged discrimination ongoing? Yes No
  • When did the last act of discrimination occur? Enter the date (mm/dd/yyyy)*
  • * Required fields

    Use the submit button below to e-mail your completed form to the intake officer:
    If you prefer, you may call, mail or fax the completed questionnaire to the Equal Opportunity Department at:
    City of Phoenix Equal Opportunity Department
    Compliance & Enforcement Division
    251 W. Washington St. 7th Floor
    Phoenix, AZ 85003
    602-262-7486/voice     602-534-1557/TTY     602-495-0517/fax
    The Equal Opportunity Department will make every attempt to contact you within 48 hours of receipt of your complaint.

    Contact information for employers outside of Phoenix or who have more than 14 employees:

    Within 180 days from the most recent alleged discriminatory incident:
    Arizona Attorney General's Office, Civil Rights Division,
    1275 W. Washington
    Phoenix, Arizona 85003
    (602) 542-5263

    Within 300 days from the most recent alleged discriminatory incident:
    U.S. Equal Employment Opportunity Commission, Phoenix District Office 3300 N. Central Ave., Suite 690
    Phoenix, Arizona 85012
    (602) 640-5000

    Before you submit this form, we would like you to be aware of the city's policy on the use of its e-mail systems. The policy states that the e-mail message you are about to send: (1) is subject to public disclosure under the Public Records Law, (2) is not private or confidential and (3) is retained for one month.