I, First Name* Last Name* of Street Address* Address Line 2* City* State* Postcode* authorise Human Rights Advocates (HRA) or any representative from HRA to act on my behalf in relation to the complaint I have made to the [insert relevant state]* Human Rights Commission/Tribunal. I understand that officers of the Commission/Tribunal will deal directly with Human Rights Advocates and their representatives, in relation to this complaint. field. I authorise HRA to: · Provide information and documents to the Commission/Tribunal in connection with the Commission’s/Tribunal's assessment, investigation, and conciliation of my complaint. · Receive information and documents from the Commission/Tribunal about my complaint. These documents could include responses provided by the respondent and correspondence from the Commission/Tribunal. · Submit any relevant medical information regarding my complaint. · Discuss my complaint with officers of the Commission/Tribunal. I understand that I can withdraw my authority to act at any time by contacting the Commission/Tribunal. I understand that the Commission/Tribunal will use and store my personal information in accordance with the Privacy Act.
When this complaint is lodged, some Commission’s/Tribunal's have a confidential survey asking the following. Please answer any questions you are comfortable answering.