Public Accommodations Complaint Intake Form

Human Relations - Public Accommodations Complaint

HUMAN RELATIONS DEPARTMENT CIVIL RIGHTS DIVISION Public Accommodations Complaint Intake Form

Instructions:
Please fill out this complaint form to the best of your ability. The Department will need specific information to determine if your claim can be processed as a charge and to investigate the charge if it is accepted. Your entry will be posted as of 05/18/2013. If you have any questions while filling out this form, please call the Kansas City Department of Human Relations at (816) 513-1836.

1. PERSONAL INFORMATION
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Social Security #:
Home Phone:
Work Phone:
Pager/Mobile:

CONTACT INFORMATION: (Someone who does NOT reside with you and will know how to contact you.)
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Phone:
Please note: If any of the above information should change please notify the Human Relations Department immediately. Failure to do so could mean that your case may be closed.

2. FILING INFORMATION

Have you filed this complaint with any other agency?

Yes
No

If so, which one and on what date?

3. RESPONDENT INFORMATION: (The Respondent is the person, agency, company, etc., that you are complaining against.)
Respondent Name:
Street Address:
City:
State:
Zip:
Phone Number:

Please list the names of any of the respondent's employees who were involved in your complaint. (Clerks, managers, officers, etc.)

Name:
Title:

Name:
Title:

Name:
Title:

5. BASIS OF DISCRIMINATION

You believe that the action(s) taken against you was(were) because of your:

Disability National Origin or Ancestry Sex
Familial Status Race/Color Sexual Orientation
Marital Status Religion Gender Identity

6. COMPLAINANT STATEMENT

What did the respondent do? List each action that you believe was discriminatory. For example: I was not served, was harassed, could not fit my wheel chair, etc. Be specific regarding who, what, when and where. Then state why you believe that the treatment you received was because of the basis that you checked above.

Add all pertinent information. If you have relevant documents that are saved as files on your computer, please attach(upload) them at the end of this form. Please mail in any other documents that are not able to be uploaded and reference those documents in the following entry field.

9. WITNESS INFORMATION
If known, please provide the names, home addresses and telephone numbers of persons who may have first hand knowledge of what happened to you or who may have seen or experienced similar treatment.

Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Home Phone:
What information can this witness provide?


Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Home Phone:
What information can this witness provide?


Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Home Phone:
What information can this witness provide?

11. REMEDY
What remedy relief are you seeking?

Attach any related files Here: