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Contact Information
The Civil Rights may need to contact you for additional information.
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Contact Person
Provide the contact information for a person who does not live with you but can contact you.
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Attorney representing you in this civil rights complaint (if any):
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Employment Information
Complete this section if you are a current or former employee.
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Employer Information:
Provide the contact information for the person you would like to file a complaint against.
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Protected Activities
Please provide information below regarding your protected activities.
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Witness Information
List the name(s) and contact information of anyone who has first-hand knowledge of the harm(s) you are alleging.
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Comparison Employees
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