Name *

First Name

Last Name

Phone *

XXX-XXX-XXXX

(###)

###

####

Location of discrimination occurance *

Where did this act of discrimination occur? We only investigate complaints occurring in Harford County, MD.

Harford County, MD

Other

Type of discrimination *

What was the discrimination based on?

Racial

Sexual orientation

National origin

Religion

Age

Gender

Disability

Retaliation

Other

Date of occurance *

What date did the discrimination take place?

MM

DD

YYYY

Time of occurrence

What time did the discrimination occur?

Hour

Minute

Second

AM PM

Entity of the discrimination *

Employer

Law enforcement

Housing

Organization

Agency

Other

Have you filed a grievance with a government agency?

Yes

No

Have you filed a grievance with your union?

Yes

No

Have you retained an attorney for your case?

Yes

No

Are you seeking any support for your individual complaint or support for the widespread issue?

I am seeking support for myself as an individual

I am seeking support in addressing the widespread issue

Are you an NAACP member? *

Yes

No