[Ohio Civil Rights Commission] OCRC Employment Charge 352

Your Name (First and Last Name)

Your Street Address

Your City, State & Zip Code

Your Telephone Number

Your Alternate Phone Number (Optional)

Your Email Address

Employer Name

Employer Street Address

Employer City, State & Zip Code

Employer Telephone

County where Employer is Located (if in Ohio)

Total Number of Workers Employed

Date(s) of Discrimination - Must have occurred within TWO YEARS from the charge filing date

Indicate how you are a member of the group marked above. (Example - If you marked race, identify your race. If you marked age, identify your age and birthdate.) DO NOT IDENTIFY YOUR DISABILITY OR MEDICAL CONDITION.

Date of Hire

Position Held (or Being Sought)

If you have marked other, please briefly describe the discriminatory act.

Please write a concise statement summarizing the act(s) of discrimination and why you believe it is discrimination. In your statement, include information as to who committed the act of discrimination (name and position), any reason given for the act of discrimination, when the acts occurred and names of others treated more favorably than you.

Please intial to indicate you have read and agreed to the following statement: I understand that I will not be able to sign this form on-line. A copy will be mailed to me for a notarized signature. An investigation will not begin until the Ohio Civil Rights Commission receives a SIGNED AND NOTARIZED CHARGE from me.

Ohio law, under ORC 4112.052(A), prohibits individuals from bringing a civil action (lawsuit) in state court until they have filed a charge with the Ohio Civil Rights Commission (“OCRC” or “Commission”) and received a Notice of Right to Sue, with some exceptions. However, if Charging Parties wish to bring a civil action in state court as soon as possible, they can request a Notice of Right to Sue immediately. If Charging Parties request a Notice of Right to Sue at the time of filing a charge of discrimination, the Commission can issue that notice after the expiration of 60 days from the date the charge was filed.

If the Charging Parties decide to bring a civil action in state court right away, during the 60-day waiting period, the Charging Parties can take advantage of the Commission’s free and voluntary mediation program.

Charging Parties may decide to continue through the full OCRC investigation process and then decide to file a civil action in state court after the Commission makes an initial determination or otherwise dismisses the charge.

In order to process your charge effectively and efficiently, OCRC asks for Charging Parties to voluntarily inform the Commission of their intentions at the time of filing their charge(s). This information will not be shared with Respondents until all case records are made public. Any intentions stated below are not binding until you request and receive a Notice of Right to Sue, in writing. Please note that your case will not be impacted should your plans change.

[1] Exceptions are: 1) the person has received a Notice of Right to Sue from the Equal Employment Opportunity Commission (EEOC); (2) The Commission fails to issue a Notice of Right to Sue within 45 days after one is requested and following the 60-day hold period; (3) The civil action is seeking only injunctive relief; or (4) The case has a Probable Cause finding and the Charging Party has withdrawn the case.

Case Intentions Questionnaire (The following information is voluntary and will not be shared with Respondent until all case records are made public.)

I plan to request a Notice of Right to Sue. (You will still need to officially request a Notice of Right to Sue in writing.)

I plan to request mediation, and if mediation is unsuccessful, I plan to request a Notice of Right to Sue.

I plan to request a full investigation conducted by OCRC, which may include mediation.