UFCW Local 700
UFCW Local 700
 
 
 
 
 
 
 

 

 

 
Discrimination Questionnaire

If you work for a non-union employer and you believe that your civil rights have been violated, please fill out the following form.

Name:
Address:
City:
State
Zip Code:
Phone:
E-mail:
   
Employer:
Employer Address:
Employer City:
Employer State:
Employer Zip Code:
   
Your Position at Work:

I believe I was discrimiated against because of my:
  Race
  Color
  Creed
  Gender
  National Origin
  Religion
  Union Activity
  Family Medical Leave Act

I have been:
  Discharged
  Suspended
  Demoted
  Denied a Promotion
  Denied a Pay Raise

I have been sexually harassed:
  No
  Yes
  By a Supervisor
  By a Co-Worker

Supervisors have made derogatory statements about me: Yes No

Co-Workers have made derogatory statements about me: Yes No

Comments:

 
 
Change To Win
 
Wake Up Walmart
 
 
Rock The Vote
 
 

Local 700