IOWA CIVIL RIGHTS COMMISSION COMPLAINT FORM

 

Complaint of Discrimination under Iowa Code Chapter 216, Iowa Civil Rights Act of 1965

NOTE: A copy of this complaint will be sent to the Organization or person you are filing against.

 

(AGENCY USE ONLY)

ICRC CP#___________________________________   Iowa Civil Rights Commission

Local Commission#____________________________  400 East 14th Street

EEOC#______________________________________  Des Moines, IA 50319-1004

515-281-4121 / 800-457-4416 / Fax: 515-242-5840 / http://www.state.ia.us/government/crc

 

(TYPE OR PRINT)

1. What is your legal name?

 

2. What is your mailing address?

 

City:   State:   Zip Code:

 

3. Telephone #: ( ) -

 

4. Your date of birth?     Your sex?

 

Your Race?   Your National Origin?

 

5. Below are the legal bases for discrimination.  On what basis do you feel you have been discriminated against?

 

RACE

Black     White     Asian     American Indian    

Other (please identify):

NATIONAL ORIGIN

Hispanic     Mexican     East Indian   

Arab/Afghani/Middle Eastern    

Other (please identify):

SEX

Female     Male

SEXUAL ORIENTATION

Heterosexual     Gay      Lesbian     Bisexual

GENDER IDENTITY

PREGNANCY

DISABILITY
(Real or Perceived)

Physical     Mental

RELIGION/CREED

Please Identify:

COLOR

Light skinned     Dark skinned

AGE
(Employment or Credit Only)

Discrimination against:

Older Persons

Younger Persons

FAMILIAL STATUS
(Housing or Credit Only)

Presence of children

MARITAL STATUS
(Credit Only)

Discrimination against:

Married Persons

Non-Married Persons

RETALIATION

Because I filed a prior civil rights complaint, opposed a discriminatory practice or participated as a witness in an anti-discrimination proceeding.



6.
Please check the AREA in which the discrimination occurred. 

Employment                       Public Accommodation                   Housing 


Education                            Credit


 

7. Please check the ACTION that the Company took against you. (Check all that apply)

 


Demotion

Denied Accommodation/Modification

Denied Benefits

Denied Financial Services

Denied Service

Disciplined/Suspended

Eviction

Failure to Hire

Failure to Promote

Failure to Rent

Failure to Train

Forced to Quit/Retire

Harassment

Laid-Off/ Failure to Recall

Reduced Hours/Pay

Sexual Harassment

Terminated

Treated Differently

Undesirable Assignment/Transfer

Unequal Pay


 

Other:  


 


 

8. What is the Full Legal Name of the Organization that discriminated against you? 

[This Organization will be charged with discrimination and will be given a copy of your complaint.]

 

 

What is their mailing address?

 

City:   County: State:

Zip Code:   Telephone #: ( ) -

 

9. Name the Parent Organization or Corporate Office of the organization listed in #8.

[This Organization will also be charged with discrimination and will be given a copy of your complaint.]

 

 

What is their mailing address?

 

City:   State:

 

Zip Code:   Telephone #: ( ) -

 

10. Where did the discrimination occur?

 

City:   County: State:

 

11. What does the organization do?  What services does the organization provide?

 

 

12. If Employment is the Area, give approximate number of ALL employees (full-time &

part-time) at ALL employer locations nationwide (VERY IMPORTANT):

 

 

4-14             15-19           20-100         101-200       201-500       500+

 

 

13. Have you filed this complaint with any other Federal, State, or Local anti-discrimination agency?     

Yes                          No

 

If yes, what agency? When?

 

 

14. If you are claiming harassment, who harassed you?

[This person will be charged with discrimination and will be given a copy of your complaint.]

 

Name:

Title:

Work or Home Address:

 

Name:

Title:

Work or Home Address:

 

Name:

Title:

Work or Home Address:

 

 

15. What was the date of the most recent discriminatory incident? (Month Day, Year)

 

 

 

16. If Employment is the Area, what is your hire date or application date?

 

  (Month Day, Year)

 

Are you still employed by the Organization listed in #8?           Yes              No 

 

If no, when did your employment end?   (Month Day, Year)

 

17. Brief summary of allegations.  Please state why you feel your basis/ bases was/were a factor in how you were treated.  Please be sure to address each action you checked in Question #7.  (Please DO NOT identify people who may be witnesses in support of your complaint.)  (Please read the instructions before writing your brief summary.)


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I certify under penalty of perjury and pursuant to the laws of the State of Iowa and the laws of the United States of America that the preceding charge is true and correct.

 

 

X __________________________________________________    ______________

Signature of Complainant                                                      Date

 

Please be sure to attach the Contact Information form
and the Authorization Release Form with your complaint form.