Human Relations Commission: Discrimination Pre-Interview Form

 Step 1 of 1

This form is used by the Evansville-Vanderburgh County Human Relations Commission (HRC) as a means of obtaining basic information from you.

IMPORTANT!!

Please note: Submitting out this form does not constitute a formal complaint. After you submit this form and the Human Relations Commission is able to review it, an HRC investigator will contact you to explain the process and gather further information regarding your allegations. Following this initial interview, if you decide to file a complaint, the investigator will assist you with the next steps.

Please fill out the form below

* Denotes a required field

Complainant

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ZIP*
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Second portion of ZIP Code is optional.
Phone Number*
-- ext
Alternate Phone 
-- ext
 
Date of Birth*
 Date of Birth

RESPONDENT'S INFORMATION (Information of Employer/Housing Provider Who Discriminated Against You)

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ZIP 
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Second portion of ZIP Code is optional.
 

Please Provide the name of someone not living in your home who knows where you are at anytime

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ZIP*
-
Second portion of ZIP Code is optional.
Phone*
-- ext
Alternate Phone 
-- ext
 

Nature of Inquiry

The alleged discrimination occured in:*
Date of Incident/Discrimination*
 Date of Incident/Discrimination
Please provide the Reason for the difference in treatment*
What action was taken against you that you believe to be discriminatory? Please check the appropriate box.*

Please Answer the Following

What was your date of hire? 
 What was your date of hire?
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Please answer the following:
If charging an Employer with discrimination, are you currently employed with them?*
If you are no longer employed with your employer, what is your date of termination/resignation? 
 If you are no longer employed with your employer, what is your date of termination/resignation?
 
Are you currently employed by another employer?*

If you are currently employed by another employer, please answer the following:

 
Date of Employment 
 Date of Employment
 
 
 
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Please Answer the Following:

 
 
What was the most recent date of the alleged discriminatory action that was taken against you?*
 What was the most recent date of the alleged discriminatory action that was taken against you?
 
 
Do you have any witnesses to support your claim of discrimination? 
 
 
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If charging a Housing Provider with discrimination, are you facing eviction?*
*
 
Please click Submit below when finished to send your inquiry to our offices.
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