Human Rights Non-Housing Complaint Form

DES MOINES CIVIL & HUMAN RIGHTS COMMISSION
602 Robert D. Ray Drive, Des Moines, Iowa 50309
Phone: 515-283-4284 · Fax: 515-237-1408
humanrights@dmgov.org

IMPORTANT: PLEASE READ
  • This form is affected by the Privacy Act of 1974
  • This form has expandable fields for your convenience
  • This form is used to obtain information PRIOR to the complaint process
  • THIS IS NOT AN OFFICIAL COMPLAINT
  • The organization/person listed on this form will be served with a copy of your official complaint
  • Any false statements or failure to disclose information may be detrimental to the case and may result in an adverse finding.
You can deliver this complaint form to us in several ways:
  • The easiest way is to click the Submit button
  • Save the complaint and then manually email it to us at humanrights@dmgov.org
  • Mail the form to us at Des Moines Civil & Human Rights Commission, 602 Robert D Ray Drive, Des Moines, IA 50309 · Fax the form to us at 515-237-1408
  • Bring this information to us at 602 Robert D Ray Drive, Des Moines, IA 50309

Name (First, Middle, Last)


Date of Birth


Current Address (Number and Street)


City


State


County


Email Address


Home Phone Number and Area Code


Alternate Phone Number and Area Code


May we leave a voicemail?
Yes
No

Preferred contact method
Mail
Email
Phone

Name of person to contact if you cannot be reached


Contact person's phone number with area code


Name of attorney or representative (if applicable)


Date of most recent discriminatory incident


Gender


National Origin (country of origin or ancestry)


Race (check all that apply)
 Asian/Pacific Islander
 Black/African American
 Indigenous American/Native
White
 Hispanic/Latino
Other

Best time to be reached
Morning
Afternoon
Evening

Basis of discrimination - discrimination was because of (check all that apply)
 Ancestry (place of origin, ethnicity or accent)
 Association (with protected class)
 Color - Light Skinned
 Color - Dark Skinned
Creed
Familial Status
Gender Identity
Lawful Source of Income
Mental Disability
National Origin
Physical Disability
Race
Religion
 Retaliation (check only if you filed a prior complaint with us or opposed a discriminatory practice)
Sex/Gender
Sexual Orientation

Area(s) of Discrimination - the acts of discrimination were related to (choose any that apply)
 Employment
 Municipal Practices
 Public Accommodations
 Other

Name of the business or service provider you believe discriminated against you


Address of the business or service provider you believe discriminated against you (Number and Street)


City of the business or service provider you believe discriminated against you


State of the business or service provider you believe discriminated against you


Zip Code of the business or service provider you believe discriminated against you


Contact Person (owner, manager, official) of the business or service provider you believe discriminated against you


Position of Contact Person


Phone Number and Area Code of Contact Person


Type of Business


Please list other names of the company (parent organization or corporate office).  Include business name, address, city, state, zip code, contact person, position, and phone number with area code


Identify the person who discriminated against you (include their names and title/position)


If you are claiming harassment provide the Name, Position/Title, Date of Harassment, and Location


If discrimination occurred in the area of employment please answer this question - What was your hire date or application date?  
Include:  Name of witness, Position, Phone Number, Address, City, State, and Zip Code


If discrimination occurred in the area of employment please answer this question - Are you still employed by this organization?
 Yes
 No

If discrimination occurred in the area of employment please answer this question - If you are no longer employed by this organization indicate the date of termination


If discrimination occurred in the area of employment please answer this question - What was your title/position during employment?


If discrimination occurred in the area of employment please answer this question - How many people does this company employee (include full-time and part-time employees at ALL locations)
 Less than 4
 4 to 14
 15 to 100
 101 to 200
 201 to 500
 Over 500


Provide a witness you feel can provide evidence in your support.  Include the Name of witness, Position, Phone Number, Address, City, State, and Zip Code.


If you have a 2nd witness - Provide a witness you feel can provide evidence in your support.  Include the Name of witness, Position, Phone Number, Address, City, State, and Zip Code.


Please indicate actions the Company, Organization, and/or Persons took against you.
 Failure to hire
 Demotion
 Denied Promotion
 Denied Benefits
 Disciplined
 Suspended
 Fired/Constructive Discharge
 Denied Equal Wages
 Harassment (not sexual)
 Retaliation
 Pregnancy Discrimination
 Sexual Harassment
 Denied Service
 Denied Access
 Treated Differently
 Involuntary Transfer
 Changed terms or conditions of employment
 Denied reasonable accommodation (for disability or religion)
 Other

Complaint Summary (you can cut and paste from a Word Document):
1. Please fill in the particulars of your complaint, being as specific as possible, and include who discriminated, when it happened, where it happened, and why you believe it happened.  
2. Remember to state why you feel you were discriminated against. Provide names and dates if you have them.
3. The Complaint must be filed with the Des Moines Civil & Human Rights Commission within 300 days of the date of the most
recent discriminatory incident.


When did the first act of discrimination occur (date)?


Why do you think it was based on your protected class (age, disability, race, religion, sex, etc.)?


Are you aware of other individuals from you who were treated better under the same or similar circumstances?
Yes
No

If yes, please indicate the person(s) name, their characteristics, and how they were treated better than you.


Are you aware of other individuals who were treated the same or worse as you under the same or similar circumstances?
Yes
No

If yes, please indicate the person(s) name, their characteristics, and how they were treated.


Have you filed this complaint with any other Federal, State, or Local anti-discrimination agency or group?
 Yes
 No

If yes to the previous question please list the name and date of filing


I learned about the Des Moines Civil and Human Rights Commission From (be specific)


Relief - What is the minimum relief you would accept to settle this complaint (check all that apply)
Not Sure
 Back Pay/Loss Wages
 Your Job Back
 Accommodation
 Seniority
 Benefits
 Monetary
Other

If you checked "Other" under Relief above - please describe


Would you be willing to participate in conciliation (Mediation) to seek an early resolution of your claim?
Yes
No

Would you like this complaint cross-filed with Iowa Civil Rights Commission?
Yes
No

Do you certify under penalty of perjury and pursuant to the laws of the State of Iowa and the laws of the United States of America that the preceding charge is true and correct?
Yes
No

If you certify  under penalty of perjury and pursuant to the laws of the State of Iowa and the laws of the United States of America that the preceding charge is true and correct type your name below:


Today's Date