WORKPLACE INCIDENT RECORD
Preparation worksheet | Yenra | Reviewed October 17, 2026
Guide: https://yenra.com/job-discrimination/
Age-specific questions: https://yenra.com/age-discrimination/
Official filing instructions:
https://www.eeoc.gov/how-file-charge-employment-discrimination
Official timing guidance: https://www.eeoc.gov/time-limits-filing-charge

Use this editable record to prepare for an agency or qualified adviser.
Completing it does not file a charge or preserve a deadline. Ask promptly
which process, deadline and filing action apply to your circumstances.
Store it privately. Use only records you lawfully possess; follow official
submission instructions and avoid unnecessary sensitive information.

1. CONTEXT
Date this record was started:
Employer/organization and work location:
Employer type (private, federal, state/local, other/uncertain):
Approximate workforce size, if known, and source of that information:
Applicant/employee/other relationship:
Decision or conduct of concern:
Why you believe a protected characteristic or activity mattered:

2. EVENT RECORD (copy this block for each event)
Event date/time (mark estimates):
Date this note was written:
Location and people involved:
What I directly observed or received:
Exact words, if documented; otherwise label paraphrase:
Employer's stated reason and where it appears:
What another person reported; their source of knowledge:
My interpretation (keep separate from observed facts):
Document identifier(s):
Witness and what they directly observed:
Missing information / question to investigate:

3. DOCUMENT INDEX
ID | Date | Sender/creator | Description | Secure storage location

4. CONTACTS AND SUBMISSIONS
Date | Office/adviser | Question | Answer | Next action | Reference number
What did I submit: inquiry, appointment request, internal report, charge,
or another document? Confirm the category with the receiving office.
Filing confirmation and date:
Who confirmed the applicable deadline and required filing action:

5. AGE-SPECIFIC QUESTIONS, IF RELEVANT
Age at the time of the event:
Hiring/promotion/training/layoff/retirement issue:
Selection criteria or comparison information actually available:
Severance offer received, response date and revisions:
Questions about individual/group offer and required disclosures:
Qualified adviser reviewing the actual agreement:

6. NEXT QUESTIONS
Coverage and responsible entity:
Applicable process and deadline:
Access/language assistance needed:
Potential retaliation concerns and separate event dates:
What I still do not know:
Next agreed step and follow-up date: