Discrimination Complaint Form
Tell Us About Your Complaint
Date the alleged discrimination occurred
*
-
Month
-
Day
Year
Date
Classification of the party against whom you are filing your complaint
*
County Employee
County service or policy
The alleged discrimination happened because of one or more of the following Carroll County protected categories
*
Race
Color
National origin OR Ancestry OR Language
Age
Religion
Sex (including Gender Identity or Sexual Orientation)
Please describe why you believe these actions were taken against you and how they are related to your protected class. Describe the incident that occurred, or the situation which you feel qualifies as discriminatory act, practice, or policy.
*
Is the discrimination still occurring?
Yes
No
Name and address of government agency or place where the discrimination happened
*
Add an additional person or agency
if needed
Is the person filling out this complaint the same person against whom the alleged discrimination occurred?
*
Yes
No
Enter your: Name, Phone Number, Email address in the box below if you answer “No” to this question
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
INFORMATION CONCERNING THE PERSON AGAINST WHOM THE ALLEGED DISCRIMINATION OCCURRED
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Upload or Drag fi les here which provide information or documentation that support your claim of discrimination
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