Civil Rights Complaint Form

Date

MonthDayYear
Hour Minutes
Civil Rights Complaint Form
See the full Jefferson County Department of Human Services Client Civil Rights Plan and Complaint Process Policy & Procedure here.
Complainants Name

First NameLast Name
Complainants Email
example@example.com
Complainants Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
I prefer to be contacted by telephone at:

HomeWork
At the following time(s)
and Day(s)

MondayTuesdayWednesdayThursdayFriday
I wish to complain against: County/State Program:
Specific individual(s)
I believe that I was discriminated against because of:

AgeAncestryColorCreedDisabilityEthnic or National OriginGender Identity and ExpressionPolitical BeliefsRaceReligionSex or GenderSexual OrientationOther (Specify)
This discrimination resulted in the following unfair treatment (Please be specific):
Date Discrimination Occurred

MonthDayYear
Why do you believe the unfair treatment you described was discrimination?
What is your desired remedy?
List the names, job titles and telephone numbers (if possible) of witnesses, or others you feel could provide evidence.
Have you attempted to resolve your problem by discussing the matter with someone in management?

YesNo
Please provide the name and title of the person(s) and state what happened
This information is voluntary and is requested for statistical purposes
Sex

FemaleMalePreferred option
Racial/Ethnic Group

BlackAmerican Indian or AlaskanAsian or Pacific IslanderHispanicWhite
I certify that all statements are true, complete and correct to the best of my knowledge.
Signature

Powered by Jotform SignClear
Should be Empty:

Civil Rights Complaint Form

This information is voluntary and is requested for statistical purposes