City of Detroit - Civil Rights, Inclusion & Opportunity (CRIO) CLAIMANT QUESTIONNAIRE - Intake Form
Please complete this form to start the process of investigating your claim of a discrimination or harassment violation.
All claims of violations must occur within the City of Detroit limits.
The claim of a violation must have occured within one year of the date of this completed Claimant Questionnaire.
Claimants's Complete Address
Claimants Telephone Number
Please indicate the best number to contact you.
Please provide the best email address to contact you
Person or agency you are alleging discrimination or harassment against
Respondent's Complete Address
Respondent's Telephone Number
Have you filed a complaint with another agency?
What was the outcome of your complaint?
What is the area of your complaint?
Medical Care Facilites
Please select the type of discrimination.
Sexual Orientation/Gender Identity
Public Benefit Status
This section is for Employment Complaints Only
Please complete this section if your claim of discrimination is for your employer.
Employer's Type of Buisness
How many employees does the respondent have?
Your Supervisor's Name and Title
USE THE NEXT SECTION TO DESCRIBE THE ALLEGED DISCRIMINATION OR HARASSMENT VIOLATION
DESCRIBE THE DISCRIMINATION - In Detail
Complete this area to detail the incident or action that lead to you filing this claimant questionnaire.
What information or evidence do you have which might prove that the action was discriminatory?
Please upload any non-confidential documents
Witnesses name, address and contact number
Please give contact information for all your witnesses that may help prove your claim of discrimination
Claimants Electronic Signature
This signature certifies that the information that was provided is true and verifiable.
Enter today's date
Send me a copy of my responses
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