Experiences of Discrimination Form

Experiences of Discrimination Form

TwoSpirit, Trans, and Gender Diverse people often experience discrimination, harassment, or mistreatment when seeking to access housing, using public accommodations, medical or mental health care, government services, or in their workplaces or schools. Gender Justice League collects these experiences to better understand and advocate for our community with policymakers, government human rights offices, and elected officials. Sadly, Gender Justice League does not currently offer legal representation to individuals, but we will do our best to respond with free community legal services or information about your rights.
How We Use This Information:

Gender Justice League will use the following information for informational purposes only. This complaint form does not go to an official government agency in charge of investigating complaints of discrimination. By completing this form, you acknowledge that Gender Justice League may used anonymized data (such as the type of discrimination you experienced) to educate policy makers and the public about the types of discrimination that TwoSpirit, Trans, and Gender Diverse people experience. Your answers will be kept confidential by Gender Justice League and that your information will not be shared with third parties except with your explicit written permission. Although we acknowledge that third party data breaches can happen and are out of our hands, Gender Justice League will do everything in our power to maintain the confidentiality of your personally identifying information.
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Incident

MonthDayYear
Date
Location of Incident

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Description of the Incident
Were there any witnesses? (Check all that apply)

YesNoUnsureOther
Witness Names

First NameLast Name
Did you report this incident to any authority?

YesNoOther
Nature of Discrimination (please check all that apply)

Gender Identity or ExpressionSexual OrientationRaceDisabilitySexEthnicityImmigration StatusHIV statusAgeNational Origin
Area of Discrimination (please check all that apply)

HousingPublic BenefitsPublic Accommodations (ie: bathrooms)Identity Documents (e.g. license, passport; gender marker or name change applications)EmploymentHealthcare or Mental HealthcareEducationCredit, Insurance, or BankingGovernment AgencyPolice, Jails, or Prison SystemVoting or Civic ParticipationCourts or Judicial System
Was this Incident (check all that apply)

In Washington StateIn Another StateWith A Federal Government AgencyOther
Please provide any supporting evidence (documents, photos, etc.)

Cancelof
By Signing this form I acknowledge
1. Gender Justice League may use anonymized and non-identifying information provided here for educational purposes to policy makers and the public about the types of discrimination that two-spirit, trans, and gender diverse people experience.
2. I understand that my personally identifying information will be kept confidential within Gender Justice League.
3. I give Gender Justice League permission to contact me at the email or phone number provided to give me information about my rights and where I can file a discrimination complaint.
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