LCHR Employment Discrimination Intake Questionnaire

Please complete the entire form below and submit it. You cannot save your progress if you choose to submit your form online.

Click here if you wish to download a paper form to fill out and return to the Louisiana Commission on Human Rights (LCHR) instead of completing the online form.

Oprime si quieres descargar un formulario traducido en español. (Click here for the form in Spanish.)

REMEMBER, a charge of employment discrimination must be filed within the time limits imposed by law, generally within 180 days or in some places 300 days of the alleged discrimination. Upon receipt, this form will be reviewed to determine LCHR coverage. Answer all questions as completely as possible, and email any additional information to lburns@lchrgov.net. If you do not know the answer to a question, answer by stating “not known.” If a question is not applicable, answer “n/a.”

Personal Information

Last Name

First Name

Middle Initial

Street or Mailing Address

Apt or Unit #

City

Parish

State

Zip Code

Home Phone

(XXX-XXX-XXXX)

Work Phone

(XXX-XXX-XXXX)

Cell Phone

(XXX-XXX-XXXX)

Date of Birth

(MM/DD/YYYY)

Sex

Male

Female

Race

National Origin/Ethnicity

Do you have a disability?

Yes

Please provide the name of a person we can contact if we are unable to reach you:

Name

Relationship

Address

City

State

Zip Code

Home Phone

(XXX-XXX-XXXX)

Other Phone

(XXX-XXX-XXXX)

I believe that I was discriminated against by the following organization(s):

Employer

Union

Employment Agency

Other

(Check all that apply)

If you selected "Other" above, please specify.