Q. #1 First Name, Middle Initial, and Last Name
(example: Mary J. Doe)
Q. #2 Mailing Address
Q. #3 Telephone Number
Q. #4 National Origin is your birth Country or ancestry. (It is not necessary to give us City and State where born.)
Q. #5 Basis is the personal characteristic which accounted for the alleged discrimination.
Q. #6 Area describes the relationship between you and the organization you are filing against.
in Employment, you had or sought an employment relationship with the organization (such as a private or public employer, temp agency, etc.);
in Public Accommodation, you had or sought services from the organization (such as grocery store, gas station, police, etc.);
in Credit, you had or sought financial services from the organization (such as bank, mortgage lending institution, etc.);
in Education, you had or sought educational services from the organization (such as elementary/secondary school, college, etc.)
in Housing, you had or sought housing services from the organization (such as landlord, realtor, resident manager, etc.); or
in Retaliation, you suffered adverse action or harm because you complained about discrimination.
Q. #7. Action is the alleged discriminatory incident. (For example: in Employment, an incident could be undesirable work assignment or termination. In Housing, an incident could be denial of a rental unit or eviction.)
Q. #8 Full legal name and address of the organization responsible for the alleged discriminatory incident. (For example: Hamburger Heaven, Inc.) [This Organization will be charged with discrimination and will be given a copy of your complaint.]
Q. #9 Full legal name, address, and telephone number of the "parent" organization or the corporate office. [This Organization will be charged with discrimination and will be given a copy of your complaint.]
Q. #10 Provide the city, county and state where the discrimination occurred.
Q. #11 What does the organization make? Or what service does the organization provide?
Q. #12 Estimate the total number of employees at all locations. (Very Important)
Q. #13 Did you file a complaint alleging discrimination with another anti-discrimination agency regarding this same set of facts before you contacted the Iowa Civil Rights Commission? If so, what agency and when?
Q. #14 Legal name and job position of person(s) who harassed you. (For example: Susan K. Smith, Supervisor) Use this person's name in the narrative (Q. #17) and briefly describe the harassment. [This person will be charged with discrimination and will be given a copy of your complaint.]
Q. #15 The most recent date something negative happened to you triggers the filing limitations period. Complaints must be filed (received at ICRC office) within 180 days of the most recent discriminatory incident.
Q. #16. In Employment, provide your start date or application date. If you are still employed, check "yes." If you are no longer employed, check "no" and provide the date your employment ended.
Q. #17. "Brief Summary of your complaint" [See page 4 of complaint form.]
In your summary, be sure to provide the following information:
1. What happened?
2. When did it happen?
3. Who made the decision for the organization?
4. What makes you think the decision or action was discriminatory?
5. Why do you believe that your basis (race, age, sex, etc.) was a factor in the organization's decision?
A. I was terminated by Mark B. Jones, my supervisor, on November 15, 2005. I believe I was fired because of my age. I am 67 years old. Younger co-workers who had less experience and inferior work records were retained.
B. Since my date of hire, June 12, 2001, I have been harassed by Jim Smith, a supervisor, because of my race. He calls me names and criticizes my work constantly. He treats me very differently from my white co-workers. I am African American. I believe he is treating me differently because of my race.
C. On December 25, 2005, I applied for a sales position at the organization's downtown location. I was qualified for the position. I am Latino. I had 10 years of experience. A non-Latino with no experience was selected over me. The organization has approximately 35 sales persons. Only 1 is Latino. I believe my national origin was a factor in the organization's decision not to hire me.
D. On July 31, 2007, I learned that I was being paid less than my heterosexual co-workers.I started working at the organization on July 1, 2007. I make $10.00 per hour. My co-workers make $11.50 per hour. We all do the same job. We have the same duties. I am homosexual. I believe that I am being paid less because of my sexual orientation.
E. I injured my back on the job. I was off work for four weeks. My doctor released me to return to work with a 30 pound lifting restriction. The Organization refused to allow me to return to work unless I was 100% with no restrictions. On December 24, 2005, the Organization refused to accommodate my disability restriction with light duty even though there were jobs I could perform.
F. I am pregnant. On September 29, 2006, I gave my boss a letter from my doctor that stated I could not lift more than 20 lbs. because of my pregnancy. My boss said the company would not accommodate my restriction. My boss said the company does not accommodate restrictions or limitations caused by non-work related temporary health conditions. I believe the company could have accommodated my restriction without causing an undue hardship.
G. I am female. Since I started working for my current employer, my supervisor has made comments about my looks, has touched me inappropriately and has indicated that my career could really go places with the company if I would have an affair with him. I complained to the owner of the company to no avail. I believe I am being sexually harassed because I am female.
Public Accommodation Examples:
A. On November 15, 2006, I went to the department store to return a shirt I had
purchased. I handed the receipt to the clerk, who responded they do not do returns.
However, the person in front of me returned merchandise without any receipt. That person
was white. I am African American. I believe I was discriminated against because of
B. On May 18, 2006, I pulled into the store’s parking lot. I parked behind another car.
Police drove by and asked the driver of the car in front of me to move. The police then
approached my car and gave me a ticket for parking in a no parking zone. I’m Latino, I believe
my national origin was a factor in being ticketed.
A. I applied to rent a house on May 15, 2006. I have two children under the age of 18. The owner took my application and said he would get back to me. He never called me so I called him back. He said the house was rented so I had a friend call the owner. The owner asked my friend if she has any children. She replied, “No.” The owner told my friend that the house was still available. I believe that I was refused rental because of my familial status (presence of children).
B. I am disabled. My doctor stated it would be therapeutic and beneficial if I kept a companionship pet such as a cat. On June 26, 2006, I presented a note from my doctor to the apartment manager and asked that their "no pets" rule be waived as a reasonable accommodation for my disability. The manager refused, and stated that they do not allow pets of any kind. I believe I was discriminated against due to my disability.
C. I am African American. I moved into this rental property in August 2006. I received an eviction notice from the management on January 23, 2007 stating that my tenancy was being terminated for violating the rules. I have seen white tenants violate the rules but their tenancy is not terminated. I believe the management is attempting to terminate my tenancy due to my race.
D. I am African American. In early-July 2006, I applied for a loan at the bank to buy a house. The loan officer reviewed my application and credit report, and then told me I did not qualify for their lowest interest rate. The loan officer told me I qualified for a loan, but at a higher rate. After I signed the loan paperwork, on August 1, 2006, I learned of another person, not African American, whose financial situation is no better than mine, who qualified for the lower rate. I believe the loan officer and the bank refused to give me the lower rate because of my race.
A. I am the parent of a twelve-year-old boy. Other boys in his class at school have been harassing him by calling him names and they push him down. On September 10, 2006, I reported the other boys’ conduct to my son’s teacher and the school principal. I expected them to stop the harassment. They did not. The harassment has continued. I know of other parents who have made complaints that the school acted on promptly. I believe the school failed to act on my complaint because my son and I are Muslim.
B. I have a disability which hinders the speed at which I read and comprehend information. Prior to taking the first exam for one of my college courses, I requested a reasonable accommodation of additional time to take the exam. My request was denied. I subsequently failed the exam. I believe I was discriminated against due to my disability.
My bank advertised personal loans at 4.5% interest. A co-worker and myself both applied for $5,000 loans. I am Latino, and my co-worker is white. We both earn about the same amount. We both have been with the company the same amount of time. My credit is good. My co-worker filed for bankruptcy six years ago. We both were approved for a loan, but my co-worker got his loan at 4.5 % and I got my loan at 6%. I believe I was discriminated against due to my national origin.