PRE-INTERVIEW INFORMATION FORM

This form is used by the Fort Wayne Human Relations Commission as a means of obtaining basic information from you.  This form does not constitute a charge.  After completing this form, you will meet with an investigator to evaluate your claim.  After the conclusion of the interview with an investigator, the investigator will then assist you in filing a charge.

The alleged discrimination occurred in:

Employment ___                     Housing ___               Public Accommodation ___               School ___

PLEASE PRINT and fill in each blank to the best of your knowledge.

COMPLAINANT:

Full Name(including middle initial): ____________________________________________________ 
Permanent Address: ______________________________________________________________

City: ___________________________ State: __________ Zip Code:  _____________
Home Phone #: _____________________________ Work Phone #: _________________________

E-Mail Address: ___________________________________Cell Phone #:   _____________________
Date of Birth:________________________

PLEASE PROVIDE the name of someone not living in your home who knows where you are at anytime:

Name:  _____________________________________Phone#:________________                                                         

Address:__________________________________City:_____________________                                                              

State:________Zip Code:__________ Relationship:_________________________

PLEASE PROVIDE the REASON for the difference in treatment: (check all that apply)

   _____Race or Color                                                          _____ Equal Pay Issue

   _____National Origin                                                        _____ Sex

   _____Ancestry                                                                 _____ Retaliation

   _____Religion                                                                   ____ Familial Status (Housing only)

   _____Age                                                                         _____Sexual Orientation

   _____Disability                                                                 _____Sexual Harassment

   _____Pregnancy                                                               _____Place of Birth                       

PLEASE PROVIDE the following:

Date of Incident/Discrimination:       __________________________________________

I learned about this agency by:         ______________________­­­­____________________

If charging an Employer with discrimination, are you currently employed with them? ________________

If charging a Housing Provider with discrimination, are you facing eviction? ________________________