BLOOMINGTON HUMAN RELATIONS COMMISSION COMPLAINT FORM

Instructions: Please complete the form to the best of your ability using the space provided. After the complaint is received, the Commission will investigate the complaint. You and/or the person/organization against whom the complaint is being made may be contacted in an attempt to resolve the complaint. If the complaint is not resolved by the investigation and if the Commission believes that discrimination may have taken place, a public hearing may be called by the Human Relations Commission to resolve the complaint. If the issue is not resolved at the public hearing, the Commission may continue to investigate. The Commission will reach a final decision regarding the complaint and will report its decision to you.

First Name *

Last Name *

Email Address *

Date of birth *

Address 1 *

Address 2

City *

State *

Zip Code *

Preferred Phone *

Number for text message contact (optional)

How do you prefer follow up contact regarding your complaint? *

phone call

email

text

letter

In your opinion, on what basis were you discriminated?

In your opinion which, of the following categories apply to your complaint? *

In your opinion, which of the following categories apply to your complaint? *

Please identify the person(s), business, or company you believe discriminated against you:

Name of company, agency, organization, individual, etc. you believe discriminated against you (Respondent): *

Manager/Owner's Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number

Email Address

PART 1: Please tell us what happened. Clearly share how you think discrimination took place in the space provided below. (If necessary, you may attach additional information to this form.)

When did the alleged discrimination occur? *

Location - Where did the alleged discrimination occur? *

Description and details - Describe alleged discriminatory act and any harm it caused you.

Were there any witnesses to the alleged discrimination? *

YES

NO

If yes, Please provide witnesses names and contact number.

What corrective action do you believe would address your complaint? *

You may include attachments here

PART 2: Please share any steps already taken, if any, concerning this matter. (for example, “talked to my union representative,” “talked to a lawyer,” “filed a complaint with the Illinois Human Relations Commission,” etc.)

Details about steps already taken

Information on this form will be kept confidential by the Human Relations Commission while the complaint is being investigated. Please note this form and any investigative materials and/or reports will be released upon proper request subject to the Illinois Freedom of Information Act or valid court order.

The Human Relations Commission will contact you to confirm receipt of this form.

I attest that the information provided on this form is true and accurate and that any false or incorrect information will void my complaint. *

Yes

No

age	color/race
disability - mental disability unrelated to ability	disability - physical disability unrelated to ability
familial status	gender
gender identity and expression	marital status
national origin	religion
sexual orientation	other other

Employment related	Public accommodations related
Housing related	Financing related
Sexual harassment	Other Other