Iowa Civil Rights Commission Complaint Form
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4IOWA CIVIL RIGHTS COMMISSION COMPLAINT FORM
515-281-4121 / 800-457-4416 / Fax: 515-242-5840 / https://icrc.iowa.gov
(AGENCY USE ONLY)
ICRC CP#_________________________________________ Iowa Civil Rights Commission
th
Local Commission#__________________________________
400 East 14
Street
EEOC#___________________________________________
Des Moines, Iowa 50319-0201
(PLEASE TYPE OR PRINT LEGIBLY)
----------------------------SECTION 1 • COMPLAINANT INFORMATION-----------------------
Your legal name: ________________________________________________________________
Your mailing address: ____________________________________________________________
City: _______________________________ State: __________ Zip Code: __________________
Telephone #: __________________________________________________________________
Email address: __________________________________________________________________
Your date of birth: __________________________ Your sex/gender: ______________________
Have you previously filed this complaint with any other federal, state, or local anti-discrimination
agency?
Yes
No
If yes, what agency? ______________________________________ When? ________________
--------------------------SECTION 2 • DISCRIMINATION INFORMATION---------------------
1. Please indicate the AREA(S) in which the discrimination occurred.
Employment
Public Accommodation
Housing
Education
Credit
Retaliation
2. Please indicate the ACTION(S) that the organization took against you.
Demotion
Failure to Train
Denied Accommodation or Modification
Forced to Quit/Retire
Denied Benefits
Harassment
Denied Financial Services/Credit
Layoff
Denied Service
Reduced Hours
Discipline
Reduced Pay
Eviction
Sexual Harassment
Suspension
Failure to Hire
Termination
Failure to Promote
Undesirable Assignment/Transfer
Failure to Rent
Failure to Recall
Unequal Pay
Other: _____________________________________________________________________
3. Please indicate the BASIS(ES) or reasons for the discrimination.
a. Do you believe you were discriminated against because of your race? ___________________
If yes, what is your race? _____________________________________________________
b. Do you believe you were discriminated against because of your skin color? _______________
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