Community Relations Commission Discrimination Complaint Form

Community Relations Commission Discrimination Complaint Form

Personal (Complainant) Information

The complainant is the individual filing the complaint of discrimination. Please provide the most accurate information for how you can be reached by mail, phone, or email. Please remember, it is your responsibility to contact the Commission to update any of the following information.

Full Legal Name*

Street Address*

City*

Zip Code*

Preferred Phone Number*

Email Address*

Complaint Information

Have you filed this complaint with any other agency?*

Yes

If yes, which agency?

If yes, when did you file this complaint with the agency?

My complaint of discrimination is in the area of*

Employment

Public Accommodation

Housing

Salary History

If your complaint is based on more than one of the previously listed reasons, include them here

The last date you believe you were discriminated against*

Do you have any special accommodations that the Commission should know about?

In specific, please list any accommodation the Commission can make for communicating with you or in the circumstance that an in-person interview would take place.

Respondent Information

The respondent is the employer or organization that allegedly engaged in discriminatory action. Please list the following information to the best of your knowledge.

Name and title of individual(s) you believe discriminated against you*

Organization name where alleged discrimination occurred*

Street Address*

City*

Zip Code*

Phone Number*

IF EMPLOYMENT - Approximate number of employees employed by respondent

Complaint Detail

IF EMPLOYMENT - Your date of hire

Please provide a brief but detailed description of the alleged discriminatory action and the events leading up to it. Please describe why you believe this action was taken because of your belonging to a protected class.*

If any, what reason were you given for the alleged discriminatory action? When was this reason given to you and by whom?

I have reviewed the information listed and confirmed that the information I provided on this form is true to the best of my knowledge.*

Yes

Please upload any files that may be relevant to your complaint:

Drag and drop files here or

Electronic Signature*

Send me a copy of my responses

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