HomeMy WebLinkAboutComplaint of Discrimination Form - 2022Complaint of Discrimination Form under City Code Title 2
Local Commission #________________ ICRC CP#________________
Office of Equity and Human Rights
City of Iowa City
410 E. Washington Street
Iowa City, Iowa 52240
Note: Please type or print
1. What is your name? _____________________________________________________________
2. What are your pronouns? ________________________________________________________
3. What is your street address? ______________________________________________________
City _________________________________________State ____________ Zip Code _________
4. Telephone number: (_____) ____________
5. What is your email address? ______________________________________________________
6. What is your date of birth? ________________________________________ Sex: ___________
7. Have you previously filed this complaint with any organization or agency? Y N
If yes, who ____________________________________________________________________
8. On what basis(es) do you feel you have been discriminated against? Please check all that may
apply.
Age Color Gender Identity
Race Creed Religion
Marital Status Sex Disability
National Origin Familial Status Retaliation*
Sexual Orientation Presence of Absence of
Dependents
Public Assistance Source
of Income
*Because I filed prior complaint or opposed a discriminatory practice.
9. Please check the area in which the discrimination occurred.
Credit Education Housing
Employment Public Accommodations
10. What is the Full Legal Name of the Business or Company that discriminated against you?
___________________________________________________________________________
11. What is the company’s mailing address?
City: __________________________ State: Iowa Zip Code: ____________
County: ________________________ Telephone Number: (_____) __________
12. What is the name of the person who discriminated against you?
_____________________________________________________________________________
13. What does that business/company do?
_____________________________________________________________________________
14. If the company named in #10 is owned by another company, what is the Full Legal Name of the
Owner Company? (Parent or Corporate Office of Company listed in #10.)
_____________________________________________________________________________
15. What is that company’s street address?
City: _________________________ State: Iowa Zip Code: ____________
Telephone Number: (_____) __________
16. Give approximate total number of full and part-time employees at all employer locations:
_______________.
17. Identify the person at the company who discriminated against you?
Name: __________________________________________________
Position/Title: ____________________________________________
18. If you are claiming harassment, who harassed you?
Name: _________________________________________________
Position/Title: ___________________________________________
19. What is the last date that something discriminatory happened to you? _________________
20. What happened on that date? Please fill in the particulars of your complaint below. Be sure to
state why you feel you were discriminated against. Be sure to address each basis you checked
on page 1.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I certify under penalty of perjury and pursuant to the laws of the City of Iowa City, the State of Iowa and
the laws of the United States of America that the preceding charge is true and correct.
X __________________________________________________ Date _______________________
Signature of Complainant