EEOC Form 5 (11/09), Charge of Discrimination Instructions
This form contains 47 fields organized into 15 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Agency(ies) Charge No(s) | ||
| Agency Charge Number | Text |
Please provide the charge number assigned by the agency or agencies.
|
| Basis of Discrimination | ||
| Race | Checkbox |
Check this box if you believe the discrimination was based on your race.
|
| Color | Checkbox |
Check this box if you believe the discrimination was based on your skin color.
|
| Sex | Checkbox |
Check this box if you believe the discrimination was based on your sex.
|
| Religion | Checkbox |
Check this box if you believe the discrimination was based on your religion.
|
| National Origin | Checkbox |
Check this box if you believe the discrimination was based on your national origin.
|
| Retaliation | Checkbox |
Check this box if you believe the discrimination was a form of retaliation.
|
| Age | Checkbox |
Check this box if you believe the discrimination was based on your age.
|
| Disability | Checkbox |
Check this box if you believe the discrimination was based on a disability.
|
| Other (Specify) | Checkbox |
Check this box if you believe the discrimination was based on a reason not listed and specify it.
|
| Other Basis of Discrimination | Text |
Please specify the basis of discrimination if it is not listed among the other options. Fill only if 'Other (Specify)' is 'Yes'.
Depends on:
Other (Specify)
|
| Genetic Information | Checkbox |
Check this box if you believe the discrimination was based on your genetic information.
|
| Charge Presentation Information | ||
| FEPA | Checkbox |
Check this box if the charge is presented to a Fair Employment Practices Agency.
|
| EEOC | Checkbox |
Check this box if the charge is presented to the Equal Employment Opportunity Commission.
|
| State or Local Agency | Text |
Provide the name of the state or local agency where the charge was presented, if applicable, as a string value. Fill only if 'FEPA' is 'Yes'.
Depends on:
FEPA
|
| Agency Charge Number(s) | Text |
Enter the charge number(s) assigned by the agency or agencies as a string value.
|
| Charge Presented To | ||
| FEPA | Checkbox |
Check this box if the charge of discrimination was presented to a Fair Employment Practices Agency (FEPA).
|
| EEOC | Checkbox |
Check this box if the charge of discrimination was presented to the Equal Employment Opportunity Commission (EEOC).
|
| Charging Party Declaration | ||
| Charging Party Signature | Text |
Please provide the signature of the charging party.
|
| Declaration Date | Date |
Please enter the date when the declaration was signed.
|
| Charging Party Signature | ||
| Charging Party Signature | Text |
Enter the full name of the charging party who is signing this form.
|
| Date Signed | Date |
Provide the date this form was signed.
|
| Complainant Information | ||
| Complainant Full Name | Text |
Please provide the full name of the complainant, including any applicable titles like Mr., Ms., or Mrs.
|
| Date of Birth | Date |
Please provide the complainant's date of birth.
|
| Complainant Address | Text |
Please provide the full street address, city, state, and ZIP code of the complainant.
|
| Home Phone Number | Text |
Please provide the complainant's home phone number, including the area code.
|
| Date of Discrimination | ||
| CONTINUING ACTION | Checkbox |
Check this box if the discriminatory action is ongoing and has not ceased.
|
| Earliest Date of Discrimination | Date |
Provide the earliest date on which the discrimination took place.
|
| Latest Date of Discrimination | Date |
Provide the latest date on which the discrimination took place.
|
| First Discriminating Entity | ||
| Entity Name | Text |
Please provide the full name of the first discriminating entity.
|
| Number of Employees or Members | Number |
Enter the total number of employees or members in the first discriminating entity.
|
| Phone Number | Text |
Provide the phone number of the first discriminating entity, including the area code.
|
| Street Address | Text |
Enter the street address of the first discriminating entity.
|
| Form Controls | ||
| Print form button | Button | |
| Notarization | ||
| Notary Information | Text |
Provide the notary's signature, printed name, title, or other official information required for notarization. Fill only if 'FEPA' is 'Yes' and when necessary for State or Local Agency Requirements.
Depends on:
FEPA
|
| Complainant Signature | Text |
Enter the signature of the complainant. Fill only if 'FEPA' is 'Yes' and when necessary for State or Local Agency Requirements.
Depends on:
FEPA
|
| Date Subscribed and Sworn | Date |
Provide the date the document was subscribed and sworn. Fill only if 'FEPA' is 'Yes' and when necessary for State or Local Agency Requirements.
Depends on:
FEPA
|
| Notarization Section | ||
| Notary Affirmation | Text |
Provide the notary's affirmation or statement regarding the charge. Fill only if 'FEPA' is 'Yes' and notarization is required by the State or Local Agency.
Depends on:
FEPA
|
| Complainant Signature | Text |
Provide the signature of the complainant. Fill only if 'FEPA' is 'Yes' and notarization is required by the State or Local Agency.
Depends on:
FEPA
|
| Date Subscribed and Sworn | Date |
Provide the date on which the document was subscribed and sworn before the notary. Fill only if 'FEPA' is 'Yes' and notarization is required by the State or Local Agency.
Depends on:
FEPA
|
| Particulars of Discrimination | ||
| Particulars of Discrimination | Text |
Provide a detailed account of the discriminatory acts, including dates, individuals involved, and any other relevant information. Fill only if 'Entity Name', 'Entity Name' if more than two agencies are named, list additional ones here.
Depends on:
Entity Name, Entity Name
|
| Particulars of Discrimination | Text |
Provide a detailed account of the alleged act(s) of discrimination, including relevant dates, locations, and individuals involved. Fill only if 'State or local Agency' has more than two agencies named
Depends on:
State or Local Agency Name
|
| Second Discriminating Entity | ||
| Phone Number (Incl. Area Code) | Text |
Please enter the phone number, including the area code, for the second discriminating entity.
|
| Number of Employees/Members | Number |
Please enter the number of employees or members for the second discriminating entity.
|
| Entity Name | Text |
Please enter the full name of the second discriminating entity.
|
| Street Address | Text |
Please enter the street address of the second discriminating entity.
|
| State or Local Agency | ||
| State or Local Agency Name | Text |
Please provide the name of the state or local agency, if applicable, that the charge was presented to. Fill only if 'FEPA' is 'Yes'.
Depends on:
FEPA
|