Your Name ____________________________________________

Address ______________________________________________

Telephone Number (Day) ________________ (Night) __________

E-mail Address _________________________________________

Date of Birth ___________________________________________

Alternate Contact in an Emergency:

Name _________________________________________________

Address _______________________________________________

Telephone Number _______________________________________

Relationship ____________________________________________

AREA OF DISCRIMINATION:

(check applicable type)

Employment ___ Housing ___ Public Accommodations ___

City Services ___

NAME OF EMPLOYER/LANDLORD/BUSINESS OR CITY AGENCY THAT
DISCRIMINATED AGAINST YOU: ____________________________

______________________________________________________

ADDRESS ______________________________________________

TELEPHONE NUMBER _____________________________________

BASIS OF DISCRIMINATION (CHECK ALL THAT APPLY):

RACE__ COLOR__ RELIGION__ NATIONAL ORIGIN__

ANCESTRY__ SEX__ PREGNANCY__ SEXUAL HARASSMENT__

DISABILITY__ PERCEIVED DISABILITY__ SEXUAL ORIENTATION__

GENDER IDENTITY__ MARITAL STATUS__

AGE__ (DOES NOT APPLY TO PUBLIC ACCOMMODATIONS)

RETALIATION__(DOES NOT APPLY TO PUBLIC ACCOMMODATIONS)

ADDITIONAL BASES FOR HOUSING DISCRIMINATION:

SOURCE OF INCOME__ PRESENCE OF CHILDREN__

IF YOU ARE CLAIMING EMPLOYMENT DISCRIMINATION, ANSWER THE FOLLOWING QUESTIONS:

How many employees does the company have at all sites in total (approximate?)

What is the address for the corporate office if there is one?

____________________________________________________

____________________________________________________

What issue was involved?

__failure to hire __discipline __failure to promote __termination

__layoff __harassment __different treatment __difference in pay

__difference in benefits __difference in perks __other

IF YOU ARE CLAIMING HOUSING DISCRIMINATION, ANSWER THE FOLLOWING QUESTIONS:

What kind of situation was it?

__denial of rental unit __denial of sale __intimidation by neighbors

__steering by agent or broker __difference in rent __denial of mortgage

__difference in mortgage rates __harassment or inappropriate comments?

__other

If rental units are involved, how many rental units does the landlord have?

IF YOU ARE CLAIMING PUBLIC ACCOMMODATIONS DISCRIMINATION, ANSWER THE FOLLOWING QUESTIONS:

Identify your issue:

__refusal of service __not accessible to disabled __harassment

__different treatment __steering/biased advertising

IF YOU ARE CLAIMING CITY SERVICES DISCRIMINATION, ANSWER THE FOLLOWING QUESTIONS:

What Department was involved?

What is your issue?

__refusal of service __not accessible to disabled __harassment

__different treatment

IDENTIFY YOURSELF IN TERMS OF THE BASIS OR BASES YOU CHECKED OFF, FOR EXAMPLE, "I AM BLACK" OR "I AM A DISABLED PERSON."

IF YOU ARE CLAIMING RETALIATION, ANSWER THE FOLLOWING QUESTIONS:

Did you file a previous discrimination complaint against your employer/landlord? __Yes __No

When and what was the basis?

What agency did you file with?

Did you complain of discrimination to management before?__yes __no

When and what were the circumstances?

Were you ever a witness in a discrimination case or internal investigation of a discrimination claim?

When and what were the circumstances?

Did you ever complain to management about policies, practices or decisions not directly affecting you being discriminatory? __yes __no

When and what were the circumstances?

PROVIDE A BRIEF DESCRIPTION OF WHAT OCCURRED (Who, what, when - it is important to give dates):

NAMES OF WITNESSES:

NAME _______________________________________________

ADDRESS ____________________________________________

____________________________________________________

TELEPHONE NUMBER ___________________________________

What can the witness attest to?



WHEN FINISHED, PLEASE PRINT OUT AND FAX THIS FORM TO 215-686-4684.