Production Supervisor Case Manager
Resume:
Utah Antidiscrimination & Labor Division FOH
Employment Discrimination LOR
*** **** *** *****, *** Floor Intake Waiver
INTAKE QUESTIONNAIRE LOH
PO Box 146630 Salt Lake City, UT 841**-****-***
Phone: 801-***-**** 300
Fax: 801-***-****
Email: **************@****.***
DO NOT WRITE ABOVE THIS LINE - FOR UALD STAFF ONLY UTAH LABOR Utah Antidiscrimination COMMISSION and Labor Division This form does not represent a Charge of Discrimination with the Utah Antidiscrimination and Labor Division (the
“Division”). In order to file a Charge with the Division, you must first complete and return all four pages of this form and return it to the Division by e-mail to **************@****.***, or mail to the address above. REMEMBER, a charge of employment discrimination must be filed with the Division within the time limits imposed by law, which is 180 days from the date you knew about the discrimination. However, in cases within 300 days, the Division will process and waive the charge to the Equal Employment Opportunity Commission. When the Division receives this form, it will review it to determine jurisdiction. Answer all questions completely, and attach additional pages, if needed, to complete your responses. If you do not knowthe answer to a question, answer by stating “not known.” If a question is not applicable, write “NA.” (TYPE or PRINT). The Division will use the information in this Intake Questionnaire to draft a Charge and send it to you. The Division can only open a case alter it has received your signed, notarized Charge back. To help the Division identify the correct Employer, provide a copy of a W-Z or paycheck^with this Questionnaire, where available. Failure to do so may result in a delay in creating a charge.
I am unable to because:
First Name: / Shj'fL- MI:
3/& /Vron£t~ (ur*>f- Apt or Unit #:.
County: Bchf. (S/dcs" State: (Zip: —<T j
Work: Cell: 7/0
[have attached a copy of a W-2 or paycheck
1. Personal Information
Last Name: _
Street or Mailing Address:
City: CfL]
Phone Numbers: Home: (J )
YOU MUST PROVIDE THE DIVISION WITH YOUR EMAIL ADDRESS: Please be advised that the Division will send all written correspondence via e-mail unless you elect to receive communications with the Division via U.S. Mail and opt out of e-mail communication below:
Check this box to opt out of e-mail communication and for all communication with the Division to be via U.S. mail. Email Address: ~hcLW) M/fe <c/OSlr e/ ^ Date of Birth: (MM/DD/YYYY) - Sex: Male Female Intersex Decline to specify Do You Have a Disability? Yes No Please answer each of the next three questions:
i. Are you Hispanic or Latino? Yes ETNo
ii. What is your Race? Please choose all that apply. American Indian or Alaskan Native Asian 0"White
Black or African American Native Hawaiian or Other Pacific iii. What is your National Origin (country of origin or ancestry)?_ Please Provide The Name Of A Person We Can Contact If We Are Unable To Reach You: Name; Relationship: Address: City: State:
Home Phone: _ _Other Phone: _ Email: _Zip Code:_
1 of 4
Husband
X
Lane Petersen
X
Lane Petersen
318 N 600 W Brigham
2. Employer Information: I was discriminated against by the following type(s) of organization(s): (Check those thatapply.)
(Ef'Employer Union Employment Agency Other: (Please specify). Organization Contact Information (If the organization is an employer, provide the organization name listed on your W-2 tax form OR paycheck, and the address where you actually worked. If you work from home, check here and provide the address of the office to which you reported.) If more than one employer is involved, attach additional sheets. Organization Name1: <Pf'p£\f Op—/7Mh0J2 Alternate Name for Your Employer2 Address: County: City: State: Zip: Phone: Type of Business: Job Location: (if different from above) Human Resources Director or Owner Name: ... Phone: . Number of Employees in the Organization at All Locations: (Check one) t&jnj
Fewer than 15 El^or more Number of employees unknown V'0^rC& 3. Your Employment Data (Complete as many items as you are able.) Are you a federal employee? ) Yes No Date Hired: OcJ~Zd>ZI Job Title: Ajkfvee A&Lfe/'__ Job Title At Hire: Pay Rate When Hired: Last or Current Pay Rate: Date Quit/Discharged; Quit Terminated Forced to quit Currently employed 0-^ Name and Title of Immediate Supervisor: (SpEDi —£bpe-f{/'So-f' IpJspO, 6e<£L, fedobj - OC$ 5 If Job Applicant, Date You Applied for Job: Job Title Applied For 4. Reason (Basis) for Your Claim of Employment Discrimination: FOR EXAMPLE, if you feel that you were treated worse than someone else, or subjected to unwanted conduct, because of race, you should check the box next to Race. Ifyou feel you were treated worse, or subjected to unwanted conduct, for several reasons, such as your sex, religion and national origin, you should check all that apply. If you complained about discrimination, participated in someone else’s complaint, or filed a charge of discrimination, and a negative action was threatened or taken, you should check the box next to Retaliation (listing the date(s) of complaints, and people you complained to below).
Race Sex DAge Disability Gender Identity Sexual Orientation National Origin Religion Retaliation
Pregnancy Color (typically a difference in skin shade within the same race) Genetic Information
Religious Liberty (You expressed your religious or moral beliefs in the workplace or religious, political, or personal convictions, outside of the workplace) Other: (Specify) Please specify your color, religion, gender identity, or national origin, if checked above 5. What happened to you that you believe was discriminatory? Include the date(s) of harm, the action(s), and the name(s) and title(s) of the personal who you believe discriminated against you. Please attach additional pages if needed. (Examples:
(1) Date: 10/02/18; Action: Discharged; Name and Title of Person Responsible: Ms. Kimberly Jackson, director (2) Date: 5/19/19; Action: Unwanted touch Name and Title of Person Responsible: Mr. John Soto, production supervisor) Include the most recent action which you feel was discriminatory. (This is important because it determines whether your charge is filed on Cooed
time.)
(1) Date:
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Action:
Name and Title of Person Responsible:_
(2) Date: Action:
Name and Title of Person Responsible:
(3) Date: Action:
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Name and Title of Person Responsible:
1 Please identify the name of the company as it is show v on your paystub paystub and/or W-2. 2 If the name commonly used to refer to your employer is something else, please provide ech
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6. Why do you believe these actions were discriminatory/retaliatory? Please attach additional pages ifneeded. J=ZL_LtQjAA/).. hrij f_Z?l£b_udogf)
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8. Describe who was in the same or similar situation as you and how they were treated. For example, who else applied for the same job you did, who else had the same attendance record, or who else had the same performance? Provide the race, sex, age, national origin, religion, gender identity, sexual orientation, pregnancy status, or disability of these individuals, if known, and if it relates to your claim of discrimination. For example, if your complaint alleges race discrimination, provide the race of each person; if it alleges sex discrimination, provide the sex of each person; and so on. Use additional sheets ifneeded. Person(s) in the same or similar situation as you, who was/were treated better than you? Full Name Race. Sex, Age. National Origin. Religion or Disability Job Title Description of Treatment Person(s) in the same or similar situation as you, who was/were treated worse than you? Full Name Race. Sex. Age, National Origin. Religion or Disability Job Title Description of Treatment Person(s) in the same or similar situation as you, who was/were treated the same as you? Full Name Race, Sex. Age. National Origin. Religion or Disability Job Title Description of Treataient ANSWER QUESTIONS 9-12 ONLY IF YOU ARE CLAIMING DISCRIMINATION BASED ON DISABILITY. If not, skip to question 13. Please tell us if you have more than one disability. Please add additional pages if needed. 9. Please check all that apply: B"fes, I have a disability
I do not have a disability now but I did have one
No disability but the organization treats me as if I am disabled 10. What is the disability that you believe is the reason for your employer treating you differently? Does this disability prevent or limit you from doing anything? (E.g., lifting, sleeping, breathing, walking, caring for yourself, working, etc.) 77 <FF\ rZFxJ i jP*'/ lit <ZL ^
VerfUQ oyJ pUft/ouQ a bold, -fM'c, f/fafan /W Saf/xvfi&J <^y 11. Did you ask your employer for any changes or assistance to do your job because of your disability? Yes No If yes, when did you ask? - Was your request verbal or written? _ Who did you ask? (Provide full name and job title of person) 27/^e ■£> e^f/oy^rer far<z
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Describe the cha }ges or assistance that you asked for: tfYl
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How did your employer respond to your request?
12. Are there any witnesses to the incidents described in this questionnaire? If yes, please identify them below and tell us what they will say. (Please attach additional pages if needed to complete yourresponse) Full Name Job Title Address & Phone Number What do you believe this person will tell us? 4
13. Have you filed a similar complaint with another agency? Y es 0-No(If yes, provide name of agency and date below:) Are you represented by an attorney? B^?es No (If yes, provide contact information of the attorney below:)
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If you would like to file a charge of job discrimination, you must do so either within 300 days from the day you knew about the discrimination. If you do not file a charge of discrimination within the time limits, you will lose your rights. Please check one:
I want to tehrto a Division employee before deciding whether to file a charge. I understand that by checking this box, I have not filed a&hafgewith the Division. I also understand that I could lose my rights if I do not file a charge in time.
[£Kwant to file a charge of discrimination, and I authorize the Division to look into the discrimination I described above. I understand that the DIVISION must give the employer, union, or employment agency that I accuse of discrimination information about the charge, including my name. I also understand that the Division can only accept charges of job discrimination based on race, color, religion, sex, gender identity, sexual orientation, pregnancy, religious liberty, national origin, disability, age, genetic information, or retaliation for opposing discrimination. Signature Today’s Date
In submitting this form, you agree to advise the Division of any change in your address/e-mail/telephone number. You also agree to notify the Division in writing if your legal representation changes during the course of the investigation. Such notice must be sent directly to the Case Manager or the Director, in care of the Division. Failure to cooperate may result in the dismissal of the charge or issuance of findings based on the information contained in the file. 4 of 4
5/16/2022
Labor Commission
JACESON R. MAUGHAN
Commissioner
KENDRA L. SHIREY
Director
State of Utah
GARY R. HERBERT
Governor
SPENCER J. COX
U. Governor
DATE:
LETTER OF REPRESENTATION
TO: Utah Antidiscrimination and Labor Division
RE: Case Number
l am the Charging Party in the above case that is currently being investigated by the UALD. I understand that pursuant to Utah Code Annotated 34A-5-107(14), the Division “cannot divulge or make public any information gained from any investigation.” In order to assist the Division in its investigation of the above case, I authorize the following individual to have access to and give information regarding this case until the matter is closed by the Division or I withdraw this permission in writing. Nameoflndividual/MyRepraentative: J7)cU^P
PhoaTnim* * ^ ^
c!AVt (&. hf'/wf.
Charging Party
(Please Print)
Chargin&Party - Signature
160 East 300 South, 3- Floor■ • PO Box 146630 • Sal. Lake City, Utah 84114-6630 • telephone 801-***-****
• facsimile 801-***-**** • Toll Free 800-***-**** • www.utah.gov
Contact this candidate