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2. Please fill in the information below. The form will be electronically submitted to the Human Rights Office. If you have any questions, please call 563.589.4190.
4. 
   
6. Name of Complainant (last, first, middle)*
8. Address*
10. Phone Number*
12. Email Address:
    Please be sure to fill in an email address if you prefer to communicate with City staff via email.
14. Date, time, location of alleged infraction*
16. Complaint against*

    1. Department
    2. Officer
18. Name of officer(s), if known
20. Badge number (if known)
22. Basis for alleged discrimination (check any you feel apply)*

    1. Race
    2. Disability
    3. Creed
    4. Color
    5. Sex
    6. Age
    7. National Origin
    8. Religion
    9. Sexual Orientation
    10. Gender Identity
24. Detail of complaint (including an explanation of the alleged discrimination, as checked above)
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field