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Intake Information Form - Dubuque Human Rights Commission

  1. Personal information:
  2. Please be sure to fill in an email address if you prefer to communicate with City staff via email.
  3. Basis(es) for alleged discrimination (check any you feel apply)*
  4. Area(s) of discrimination*
  5. What did the person and/or organization you are complaining against do?*
  6. Give approximate number of ALL employees (full-time & part-time) at ALL employer locations in Dubuque and in Iowa
  7. Are you still employed by the organization?
  8. How did your employment end?
  9. Housing Inquiries
    What is the type of property involved?
  10. Does the owner live on the property?
  11. Please describe what happened to you, being as specific as possible. Please be sure to include why you feel you were discriminated against because of the basis(es) you marked. Provide names and dates if you have them. A formal complaint must be filed within 300 days of the date of the most recent discriminatory action.
  12. Business, service provider or housing provider you believe discriminated against you information:
  13. Witnesses you feel can provide evidence in your support:
  14. Have you filed this complaint with any other Federal, State, or Local anti-discrimination agency?*
  15. Would you be willing to participate in mediation in order to seek an early resolution of your claim?
  16. Leave This Blank:

  17. This field is not part of the form submission.