Print Prescreening Questions

Please call our office for a pre-screening between 8:30 and 3:00 any weekday. In order to be prepared for your prescreening, go over the questions below and be prepared to answer each one.

Name
Address
City
State
Zip Code

Referred by:

Home Phone
Work Phone
Cell Phone
E-mail Address

Name of employer complained of
Address
City
State
Zip Code

Date of Hire
Position Title

Approximate number of employees employed by Employer all over the country
Approximate number of employees employed by Employer local (within 75 miles)
Does this employer have contracts with the federal government (if you know)?

Were You

Fired?
Demoted?
Denied a promotion?
Not hired?
Sexually harassed?
Not paid what was owed?
Other (explain)?

Please explain:

Reason given by employer?

Date of last ACT by the Employer you are complaining of:

Is that date more than 180 days ago?

Why do you believe this (these) action(s) were taken?

because of my race (state race below)
because of my sex (state sex below)
because I was pregnant
because of my religion (state religion below)
because of my ethnic background (state background below)
because of my age (over 40) (state age below)
because of my handicapping condition (state condition below)
because my employer believed me to be handicapped
because I made a workers' compensation complaint against my employer
because I made a Wage and Hour com plaint against my employer
because I complained to OSHA or other agency about my employer's activities
because I took Family or Medical leave (state how long employed before leave started below)
other- explain below

Please explain:

Have you filed a charge with the EEOC (Equal Employment Opportunity Commission)?

Yes
No
If yes, state the date you filed

Charge Number

If yes, what is the status of the charge?

Date of right to sue

Deadline to file suit (90 days after the right to sue)

Have you filed for unemployment?

Yes
No
Status of claim

Have you filed with NC DOL or other agency?

Yes
No
Status of charge

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