NAACP GR Complaint Intake Form (web version)

Date

MonthDayYear
Date
Client Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail
example@example.com
Ethnicity/Race*
Sex*
Age*
Are you a member or past member of the NAACP ?*

YesNo
If YES, identify the chapter and your membership expiration date:
Chapter
Expiration date
Respondent Details:
Incident date
Full Name (Party Your Filing Against)*

First NameLast Name
Company (If applicable)*
Name
Phone
E-mail
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact info
Name
Title
Phone
Email
Cause of discrimination or civil complaint. (check appropriate box(s))*
Other (please specify)
Please check (1) of the agencies below that you have already contacted.
Other (please specify)
Complaint
Have you made any attempts to discuss this problem with the respondent?*

YesNo
If yes (please specify when and whom was contacted)
Date
Name
Why do you believe what happened to you was based on (race/disability/sex, etc.) ?*
Are you aware of any person(s) of any other race who may have experienced similar discrimination ? If yes please provide name, phone, and email.*
Are you aware of of the organizations processes or procedures required to file an internal complaint ?

YesNo
Have you followed the process ?

YesNo
Does the organization you have identified have more than 15 employees ?

YesNo
Detailed explanation of your complaint with date(s), place(s), of the incident. Include the name(s) of all person(s) involved. Please attach additional sheets, documentation, or corroborating information.
Statement of Complaint
Please attach a copy of any written materials, disciplinary documentation or other documents which you think are important to your complaint. Please keep your original documents for your records.
Please list specifically the outcome you feel would resolve your complaint:
I declare that the information in this complaint is true and correct.

First NameLast Name
Date
Should be Empty:

Client Details:

Respondent Details:

Complaint