Complaint Form

Complaint Form
About You
Title
Your Name*
Your Address*
Suburb*
Your Postcode*
Your Email Address*
Telephone - Home
Telephone - Work
Telephone - Mobile*
Who do you think has discriminated against you?

For example, the person or company that employs you, a business or office providing goods or services, the person or organisation providing your accommodation, a school, TAFE or club
Name of person/s involved
Business/Organisation name
Their address
Suburb
Their postcode
Their telephone
What is their relationship to you?
What type of discrimination do you think you have experienced?
Please tick the box/boxes that apply*

AgeBreastfeedingFamily responsibilityFamily statusGender history (must have a Gender Recognition Certificate)Impairment or disabilityMarital statusPolitical convictionPregnancyPublication of personal details on fines register websiteRaceRacial harassmentReligious convictionSexSexual harassmentSexual orientationSpent conviction (Spent Conviction Act 1988)Victimisation (for complaining about discrimination)Victimisation (for making a public interest disclosure under the Public Interest Disclosure Act 2003)Other
If Other - please explain in the box provided
Where did it happen?
Please tick the box/boxes that apply*

Employment/WorkGoods, services and facilitiesEducationAccommodationAccess to places and vehiclesMembership of clubSportApplication formOther
If Other - please explain in the box provided
When did it happen?
Please enter dates
What happened to you?
Please give us all the dates and other details. We need to know: what happened, where it happened, who did it and who was involved, why you think it was discrimination. Please give us all the dates and other details you remember:
Further information
Are there any witnesses who can help with the investigation?

YesNo
Please attach copies of any documents that may help us with our investigation, such as doctor's certificates, records of conversations, letters or advertisements

Browse Files

Cancelof
How has this affected you? What loss or harm have you experienced because of what happened?
Resolving the complaint. What would you like to happen as a result of lodging this complaint?
Is anyone helping you with this complaint?
What is their name?
What is their role/job?
Helper's address
Helper's Telephone
Survey of Complainants

Purpose of the Survey: By answering the following short questions, you will help the Commission evaluate its services and make changes or modifications to make them better. You will not be identified in any data collected or published by the Commission.
What is your gender?

FemaleMaleNon-binary
In which country were you born?

AustraliaOther
Are you of Aboriginal or Torres Strait Islander origin?

NoYes - AboriginalYes - Torres Strait Islander
What is the main language spoken at home?

EnglishOther
Do you consider yourself to have an ethnic background?

NoOther
To which age do you belong?

0 - 1213 - 1718 - 2425 - 3435 - 4445 - 5455 - 6465 - 7475+
Which of the following best describes you currently?

Looking for workStudentRetiredPensionerHomemakerEmployed
Do you have a permanent disability?

YesNo
Do you have any comments?
Contact details

Equal Opportunity Commission
Telephone: 08 9216 3900 | 1800 198 149
Email: eoc@eoc.wa.gov.au | Website: www.eoc.wa.gov.au
Should be Empty:

Complaint Form

Survey of Complainants