NAACP Staten Island Discrimination Complaint Form
Report incidents of discrimination confidentially. This form is open to both members and non-members.
Your Full Name
*
First Name
Last Name
Are you a member of the NAACP?
*
Yes
No
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Preferred method of contact
Email
Phone
Type of Discrimination Experienced
*
Race or Color
Religion
National Origin
Sex
Age
Handicapped Status
Other
Date of Incident
*
-
Month
-
Day
Year
Date
Location of Incident (address, city, or place)
*
Please describe the incident in detail
*
Name(s) of person(s) or organization(s) accused (if known)
Do you have any supporting documents or evidence? If yes, please upload them here.
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Have you filed a complaint with any governmental agency?
*
Yes
No
Which government agency did you file a complaint with?
*
Enter "N/A" if you answered "No" to the previous question.
Have you filed a grievance with your Union?
Yes
No
Not Applicable
Please provide the name of your Union and your union representative.
Have you retained an attorney regarding this case?
Yes
No
Please provide the name for attorney.
What is your attorney's email address?
example@example.com
Submit Complaint
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