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.

 

 

(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.   Check the reason for the discrimination. (I was discriminated against because of my ...)

 

RACE	Black     White     Asian     American Indian     Other (please identify):
COLOR	Light skinned     Dark skinned
SEX	Female     Male
SEXUAL ORIENTATION
GENDER IDENTITY
PREGNANCY
RELIGION/CREED	Please Identify:
NATIONAL ORIGIN	Hispanic     Mexican     East Indian    Arab/Afghani/Middle Eastern     Other (please identify):
DISABILITY	Physical     Mental
MARITAL STATUS	Discrimination against: Married Persons Non-Married Persons
AGE	Discrimination against: Older Persons Younger Persons
FAMILIAL STATUS	Presence of children
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             Retaliation                                           

 

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

Reduced Pay

Sexual Harassment

Terminated

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: AdairAdamsAllamakeeAppanooseAudubonBentonBlack HawkBooneBremerBuchananBuena VistaButlerCalhounCarrollCassCedarCerro GordoCherokeeChickasawClarkeClayClaytonClintonCrawfordDallasDavisDecaturDelawareDes MoinesDickinsonDubuqueEmmetFayetteFloydFranklinFremontGreeneGrundyGuthrieHamiltonHancockHardinHarrisonHenryHowardHumboldtIdaIowaJacksonJasperJeffersonJohnsonJonesKeokukKossuthLeeLinnLouisaLucasLyonMadisonMahaskaMarionMarshallMillsMitchellMononaMonroeMontgomeryMuscatineO'BrienOsceolaPagePalo AltoPlymouthPocahontasPolkPottawattamiePoweshiekRinggoldSacScottShelbySiouxStoryTamaTaylorUnionVan BurenWapelloWarrenWashingtonWayneWebsterWinnebagoWinneshiekWoodburyWorthWright 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?

 

Address

 

City:   County: AdairAdamsAllamakeeAppanooseAudubonBentonBlack HawkBooneBremerBuchananBuena VistaButlerCalhounCarrollCassCedarCerro GordoCherokeeChickasawClarkeClayClaytonClintonCrawfordDallasDavisDecaturDelawareDes MoinesDickinsonDubuqueEmmetFayetteFloydFranklinFremontGreeneGrundyGuthrieHamiltonHancockHardinHarrisonHenryHowardHumboldtIdaIowaJacksonJasperJeffersonJohnsonJonesKeokukKossuthLeeLinnLouisaLucasLyonMadisonMahaskaMarionMarshallMillsMitchellMononaMonroeMontgomeryMuscatineO'BrienOsceolaPagePalo AltoPlymouthPocahontasPolkPottawattamiePoweshiekRinggoldSacScottShelbySiouxStoryTamaTaylorUnionVan BurenWapelloWarrenWashingtonWayneWebsterWinnebagoWinneshiekWoodburyWorthWright 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)

If no, how did your employment end?            Terminated              Quit 

 

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.