Form OMB Number 1190-NE OMB Number 1190-NE OSC Charge Form

OMB Number 1190-XXXX

U.S. Department of Justice

Civil Rights Division

Office of Special Counsel for Immigration-Related

Unfair Employment Practices (OSC) OSC Charge Form

U.S. immigration law prohibits discrimination on the basis of citizenship status with respect to the hiring, firing, or recruitment or referral for a fee of protected individuals: citizens, nationals of the United States, permanent residents, temporary residents, refugees, and asylees (excluding lawful permanent residents who do not apply for naturalization within six months of eligibility). It also prohibits discrimination on the basis of national origin (against employers with four to fourteen employees) with respect to the hiring, firing, or recruitment or referral for a fee of all individuals who are lawfully authorized to work in the United States. The law also prohibits document abuse: when an individual, business, or organization refuses to accept a valid document, specifies the documentation an individual can provide or demands more or different documents than are required for completing the Form I-9 because of an individual’s citizenship status or national origin. The law also prohibits retaliation against individuals for asserting their rights protected under the anti-discrimination provision of the immigration law, or for having participated or assisted in an investigation conducted by this office.

Charge Form Instructions:

Who can file a Charge: Anyone who alleges he or she is a victim of discrimination or an authorized person on behalf of the victim. This charge form must be mailed to the address below or faxed to (202) 616-5509 or e-mailed to osccrt@usdoj.gov within 180 days of the alleged date of discrimination. This form should be completed by typing or by legibly printing the information requested, in any language. If a question is not applicable, it should be left blank.

U.S. Department of Justice

Civil Rights Division

Office of Special Counsel for Immigration-Related Unfair Employment Practices - NYA

950 Pennsylvania Avenue, NW

Washington, DC 20530

Questions concerning this charge form can be directed to OSC by telephone at (202) 616-5594 or 1-800-255-7688 (toll free), TTY (202) 616-5525 or TTY 1-800-237-2515 (toll free).

Section 1: Injured Party Contact Information

Name and Address of the Injured Party (the person who claims to have been the victim of discrimination or retaliation):  Male  Female

Full Name:

Street or mailing address:

Apt: City: State: Zip Code:

Telephone: (Home) (Cell)

FAX: E-mail:

Would you like us to communicate with the Injured Party in another language?  Yes  No

Specify language:

What are the best times to contact the Injured Party by telephone (if not represented)?

Section 2: Injured Party’s Citizenship or Immigration Status Information

Please provide Injured Party’s citizenship or immigration status or work authorization type:

 Citizen

 National of the United States

 Lawful permanent resident: Date residency granted: (Day) (Month) (Year) Has the Injured Party applied for naturalization?  No  Yes (Date of Application): (Day) (Month) (Year)

 Asylee

 Refugee

 Temporary resident admitted under § 1160(a) or § 1255(a) (certain individuals eligible to have

their status adjusted based on amendments to the INA in the 1980’s)

 None of the above, but is authorized to work:

Expiration date: (Day) (Month) (Year)

Please specify:

 H-1  H-2  F-1/OPT  J-1  B-1  Asylee Applicant

 Freely Associated States (FAS)  Temporary Protected Status (TPS) (Country):

 Other (specify):

Alien # (for all non-citizens): Admission # (if no alien #):

Section 3: Injured Party’s National Origin and Other Personal Information

What is the Injured Party’s country of birth?

What is the Injured Party’s national origin (ancestry)?

What is the Injured Party’s date of birth? (Day) (Month) (Year)

Section 4: Type of Discrimination Alleged

Section 4: Type of Discrimination Alleged

What type of discrimination is being alleged? Check all that apply:

 National Origin Discrimination (The Injured Party was discriminated against with respect to hiring, firing, or

recruitment or referral for a fee because the Injured Party is from a particular country or part of the world, because

of the Injured Party’s ethnicity or accent, or because of limited English ability.)

 Citizenship Status Discrimination (The Injured Party was discriminated against with respect to hiring,

firing, or recruitment or referral for a fee because the Injured Party is, or is not, a U.S. citizen, or based on the

Injured Party’s immigration status.)

 Retaliation for Asserting Rights Protected Under 8 U.S.C. ' 1324b (The Injured Party filed a charge

of discrimination, complained about discrimination, participated in the investigation or case of another individual’s

discrimination claim, or otherwise asserted a right under the anti-discrimination provision, and an adverse action was

threatened or taken.)

 Document Abuse (The individual, business or organization refused to accept a valid document, specified the

documentation the Injured Party could show, or demanded more or different documents than are required for

completing the Employment Eligibility Verification (Form I-9 or E-Verify) because of the Injured Party’s

citizenship status or national origin.)

Section 5: Employer Information

Who committed the alleged discriminatory act?

Company (Employer) name:

Street or mailing address:

Suite: City:

State: Zip Code: Telephone:

If you know, does the Company operate under any other names?  Yes  No

If yes, under what other name(s)?

Number of Employees the Company or Employer employs:

 Fewer than 4  4-14  15 or more  Don’t know/Unable to estimate

Section 6: Date and Place the Discrimination Occurred and the Specifics of the Discrimination Alleged

When did the discrimination occur? (Day) (Month) (Year)

Where did the discrimination occur? Place:

City: State:

Explain in detail what happened when the Injured Party was discriminated against. Include whether the Injured Party was fired, laid-off, not hired, delayed start date, asked for additional documents, retaliated against, or other, and describe what happened in detail. (Attach additional sheets if needed. If the Injured Party has any documents to support the claim, you may attach them.

Please only send copies of documents, not originals.)

Section 7: Charges Filed with Other Federal or State Agencies Based on the Same Facts

Has a charge based on this set of facts been filed with any federal, state, or local governmental agency?  No  Yes

If yes: Full Agency Name:

Agency street or mailing address:

Suite: City: State: Zip Code:

Telephone:

Date Filed: (Day) (Month) (Year)

File No. (if known): Investigator name (if known):

Street or Mailing Address:

Section 8: Charging Party Contact Information (Injured Party or person filing charge on the Injured Party’s

behalf)

Is the Charging Party the same as the Injured Party?  Yes, the same. If yes, skip to #9.  No

If no, are you (check one):  Male  Female

Full Name: Title:

Entity Name:

Street or mailing address:

Apt: City:

State: Zip Code: Telephone:

FAX: E-mail:

What are the best times to contact the Charging Party?

S

Have you previously spoken or communicated with OSC prior to filing this charge?  Yes  No

If so, when? (Day) (Month) (Year)

If so, how?  Telephone hotline  E-mail  Outreach event

If you know, what is the name of the OSC representative you spoke to or communicated with?

ection 9: Communications with OSC

Section10: Affirmation and Signature of Charging Party

If this charge is being filed by the INJURED PARTY:

If this charge is being filed by the Injured Party:

As a person alleging that I have been injured by an unfair immigration-related employment practice, I understand that OSC may find it necessary to reveal my identity and other information during the conduct of the investigation of my charge, during any hearing or other proceeding as a result of my charge, or in limited circumstances in response to inquiries under the Freedom of Information Act. I give my consent. I affirm that, to the best of my knowledge, the information provided on this form is true.

_____________________________________________________ Date: ______________________

(Signature of Injured Party)

If this charge is being filed by an AUTHORIZED REPRESENTATIVE of the Injured Party:

I affirm that, to the best of my knowledge, the information provided on this form is true and that I am authorized to file this charge on behalf of the Injured Party. I understand that OSC may find it necessary to reveal my identity during the conduct of the investigation of this charge, during a hearing or other proceeding as a result of this charge, or in limited circumstances in response to inquiries under the Freedom of Information Act. I give my consent.

Print Representative Name:

Date: ___________________

(Signature of Authorized Representative)

Section 11: Optional Information

How did you hear of OSC? (check all that apply)

 Internet  OSC Outreach  E-Verify  SSA No Match  I-9 Form or Employer Handbook  Poster/Brochure  TV  Radio  Department of Labor (DOL)

 Equal Employment Opportunity Commission (EEOC)  State or Local Agency

 United States Citizenship and Immigration Services (USCIS)

 Union/Community advocacy group  Friend/Relative  Other (specify):

The Injured Party is: (check all that apply):

 Hispanic or Latino  Asian  Black or African American  White

 American Indian or Alaska Native  Native Hawaiian or Other Pacific Islander

 Two or more races

PRIVACY ACT STATEMENT

The authority for requesting this information from the Injured or Charging Party is contained in 8 U.S.C. ' 1324b. The information that the Injured or Charging Party provides will be used principally for investigating and processing the charge of prohibited discrimination; however, the information may also be used for other legitimate purposes, as detailed in the Department of Justice=s Federal Register Notice published in the Federal Register at 68 Fed. Reg. 47611 (August 11, 2003) describing the routine uses of the information obtained by the Civil Rights Division. The Injured or Charging Party’s failure to provide the information requested on this form could lead to the charge being dismissed or not being accepted. Knowingly making false statements on this form is punishable under 18 U.S.C. ' 1001.

Paperwork Reduction Act Notice

This request is in accordance with the Paperwork Reduction Act of 1995. The information collection

is necessary to enable the Department to process and investigate individual charges of discrimination in violation of 8 U.S.C. § 1324b as required by statutory mandate. The use of this collection instrument will facilitate this process by assisting charging parties to identify and provide the information necessary to initiate an investigation.

The estimate average burden associated with this collection is 30 minutes per charging party or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to Jennifer Sultan, Special Policy Counsel, USDOJ-CRT-OSC, 950 Pennsylvania Avenue, NW-NYA, Washington, DC 20530.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.