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2. Complainant Information
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
17. Incident Information
19. Date and Time of Incident
    Date and Time of Incident

    Date and Time of Incident
    Please detail incident report in the section below.
20. Location of Incident
    Please provide the location of incident.
22. Type of Discrimination *

    1. Race
    2. Religion
    3. Color
    4. Gender
    5. National Origin (Including Limited English Proficiency)
    6. Marital Status
    7. Age
    8. Disability
    9. Pregnancy
    10. Sexual Orientation
    11. Gender Identity or Expression
    12. Genetic Information
    13. Veteran Status
    14. Other Protected Status

    Please check all options that are applicable to your incident.
23. Other Protect Status
    If you choose Other Protected Status please list that discrimination
25. Description of Incident
    Please detail the incident
27. Please list the names and contact information of any witnesses of the incident
29. Witness Information
    Please put witness name and best number to contact this person
30. Witness Information
    Please put witness name and best number to contact this person
31. Witness Information
    Please put witness name and best number to contact this person
33. Have you filed a complaint with any other federal, state, or local agencies?*
    -- Select One --Yes No

    Please one option only.
35. Agency
36. Contact Name
38. Address
40. City
41. State
42. Zip Code
44. Phone Number
48. Preparer Information
    If complaint form is being prepared by someone who was not involved in the dispute, please fill out the requested information below. If complainant is completing this form, they are exempt from this section.
50. Name
51. Email Address
53. Phone Number
55. Complainant's Signature
    Please type name in box provided
56. Date
    Date
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit Submit and Print

* indicates a required field