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2. Personal information:
6. Name of Complainant*
8. Address*
10. Phone Number*
11. Email Address:
    Please be sure to fill in an email address if you prefer to communicate with City staff via email.
13. Date of Birth*
14. Sex/Gender*
16. Race*
17. National Orgin*
19. Date of Most Recent Discriminatory Incident*
    Date of Most Recent Discriminatory Incident
21. Basis(es) 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

    1. Sexual Orientation
    2. Gender Identity
    3. Pregnancy
    4. Familial Status
    5. Marital Status
    6. Retaliation (Because I filed a prior civil rights complaint, opposed a discriminatory practice or participated as a witness in an anti-discrimination proceeding)
    7. Association (Because I am associated with someone within one of the classes)
23. Area(s) of discrimination*

    1. Employment
    2. Public Accommodation
    3. Housing

    1. Education
    2. Credit
    3. Retaliation
25. What did the person and/or organization you are complaining against do?*

    1. Fired, laid-off, or failed to recall you
    2. Denied you accommodation/modification
    3. Denied you benefits
    4. Denied you financial services/credit
    5. Denied you service
    6. Treated you differently
    7. Disciplined/suspended you

    1. Did not hire you
    2. Did not promote you
    3. Did not train you
    4. Forced you to quit/retire
    5. Harassed you
    6. Reduced your hours

    1. Reduced your pay
    2. Gave you undesirable assignments
    3. Falsely denied housing was available
    4. Refused to rent, sell, or deal with you
    5. Evicted you
    6. Gave you unequal pay for the same work
27. Give approximate number of ALL employees (full-time & part-time) at ALL employer locations in Dubuque and in Iowa

    1. 4-14
    2. 15-19

    1. 20-100
    2. 101-200

    1. 201-500+
29. What is your hire date or application date?
30. Are you still employed by the organization?

    1. Yes
    2. No
32. When did your employment end?
33. How did your employment end?

    1. Terminated

    1. Quit
35. Housing Inquiries

    What is the type of property involved?

    1. Single family house
    2. House or building for 2, 3, or 4 families
    3. Building for 5+ families

    1. 55+ community
    2. Other
36. When did you move into this address?
38. Does the owner live on the property?

    1. Yes
    2. No
    3. Unknown
40. Detail of complaint (including an explanation of the alleged discrimination, as checked above)*
    Please describe what happened to you, being as specific as possible. Please be sure to include why you feel you were discriminated against because of the basis(es) you marked. Provide names and dates if you have them. A formal complaint must be filed within 300 days of the date of the most recent discriminatory action.
42. Business, service provider or housing provider you believe discriminated against you information:
46. Name of the business, service provider or housing provider you believe discriminated against you *
47. Address*
49. Where did the discrimination take place?*
50. Phone number*
52. Contact person & position*
53. Type of business
55. Identify the person who discriminated against you*
57. Witnesses you feel can provide evidence in your support:
61. Witness name
62. Witness Address
64. Witness phone number
68. Have you filed this complaint with any other Federal, State, or Local anti-discrimination agency?*

    1. Yes

    1. No
70. What agency?
71. When?
73. Name of your Attorney or Representative (if any)
74. Phone Number of Attorney or Representative
76. What relief are you seeking for the alleged discrimination?*
77. Would you be willing to participate in mediation in order to seek an early resolution of your claim?

    1. Yes

    1. No
79. How did you hear about the Dubuque Human Rights Commission?*
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81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field