Public Accommodations Intake Form

Thank you for sharing your public accommodations concern. Submitting this form does not mean you have filed a formal discrimination complaint. Once your intake form is received, a staff member will contact you with further instructions. We may request a meeting. Preparing and filing a discrimination complaint can be a complex matter.

SPECIAL INSTRUCTIONS AND INVESTIGATION CRITERIA:

Human Rights can only investigate discrimination that occurred within 60 days in the city limits of Greensboro. If you complaint involves events that occurred more than 60 days ago, please call our office at 336-373-2038 immediately. If you fail to complete all of the steps for filing a complaint within the legal time frame, our staff will not be able to investigate your complaint.

Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Statutes Chapter 132, their e-mail address is considered public record.

Your Name: *

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

County:*

Email address: *

example@example.com

Phone Contact Information:*

Age: *

Date of Birth: *

Date

Gender: *

Race: *

National Origin: *

Provide the details of the Agency you believe discriminated against you:

Name of Agency:*

Address:*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Agency's County:*

Agency's Phone Number:

Please enter a valid phone number.

Most recent date of alleged harm (that you believe was discrimination) to you: *

Date

Do you think this happened to you because of your (check as appropriate):*

In your own words, briefly describe what happened to you that you believe to be discriminatory. A short description of what happened will be enough at this time.*

Signature:*

Date:: *

Date