Iowa Civil Rights Commission Complaint Form (Page 2 of 4) in pdf

If yes, what is your skin color? ________________________________________________

c. Do you believe you were discriminated against because of your national origin? ____________

If yes, what is your national origin? _____________________________________________

d. Do you believe you were discriminated against because of your sex? ____________________

If yes, what is your sex? ______________________________________________________

e. Do you believe you were discriminated against because of your sexual orientation? _________

If yes, what is your sexual orientation? ___________________________________________

f. Do you believe you were discriminated against because of your gender identity? ___________

If yes, what gender do you identify as? ___________________________________________

g. Do you believe you were discriminated against because of a real or perceived disability? _____

If yes, what is your real or perceived disability? ____________________________________

h. Do you believe you were discriminated against because of your religion or creed? __________

If yes, what is your religion or creed? ___________________________________________

i. Do you believe you were discriminated against because of your pregnancy or pregnancy -

related condition? ___________________________________________________________

j. If your complaint involves employment or credit, do you believe you were discriminated

against because of your age? ___________________________________________________

If yes, do you believe you were discriminated because you are older or because you are

younger? __________________________________________________________________

k. If your complaint involves housing or credit, do you believe you were discriminated against

based on your familial status? _________________________________________________

If yes, how many children live with you? _________________________________________

l. If your complaint involves credit, do you believe you were discriminated against based on your

marital status? ______________________________________________________________

If yes, what is your marital status? ______________________________________________

m. Do you believe you were retaliated against because you reported discrimination to someone

within the organization, filed a complaint with the ICRC, or participated as a witness in an

anti-discrimination agency proceeding?

_________________________________________________________________________

If yes, what did you report or complain about, and to whom?

_________________________________________________________________________

State what happened to you as a result of your report or complaint.

_________________________________________________________________________

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Iowa Civil Rights Commission Complaint Form Page 2