Free Discrimination Complaint Form Template
Discrimination Complaint Form
Please complete all sections to ensure your complaint is reviewed promptly and thoroughly.
Personal Information
Name
Address
Phone Number
Incident Details
Date of Incident
Location of Incident
Person(s) Involved
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Name(s) |
Contact Number |
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Type of Discrimination Experienced
Check all that apply:
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Race/Color
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Religion
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Gender
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Age
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Disability
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National Origin
Description of Incident
Provide a detailed account of what occurred. Attach additional pages if necessary.
Action Taken
Have you reported this incident to anyone else?
If yes, please specify:
Desired Resolution
Describe how you would like this to be resolved.
Supporting Document
Upload a file to support the complaint.
Signature
By signing below, I affirm that the information provided is accurate to the best of my knowledge.
Name:
Date:
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