12:235-8.2 Contents of discrimination complaints

(a) The complaint alleging discrimination shall be under the oath or affirmation of the complainant, and shall be on a form prescribed by the Division.

(b) The complaint alleging discrimination shall include the following:

1. Complainant's name, address, social security number, and claim petition number, if a claim for formal hearing has been filed;

2. The name and address of the insurance carrier for the employer;

3. The date of complainant's accident;

4. Complainant's occupation and wages;

5. Complainant's current employment and wages;

6. Complainant's occupational duties and indication as to whether he or she is able to perform those duties;

7. The date and reason for complainant's termination of employment;

8. The factual and legal reasons for alleging discrimination;

9. Such other information as requested by the Director.