Instructions:
Required fields have an * in the label. (Example: Name*)
Most read-only fields have a grey background. Read-only checkboxes are dimmed.
Report Discrimination Form
Discrimination Category
Additional Information (informacion adicional)
If you allege more than one discriminatory action, please enter the most recent date.
Phone # (Numero de telefono):
Name (Nombre):
Email (Correo electronico):
*
Date of incident (fecha del incidente):
*
Race (La raza)
National Origin (origen nacional)
Sex (sexo)
Age (edad)
Disability (discapacidad)
Describe (describer):
Category
Category
Select a Category
Problem
Problem
Problem
*
Knowledge Base
Scripts
Religion
Request #