Pre-Interview Information Form

This form is used by the Fort Wayne Human Relations Commission as a means of obtaining basic information from you. IMPORTANT!! Please note, filling out this form does not constitute a formal complaint. After submitting this form, an investigator will contact you to explain the process and gather further information regarding your allegations. Following this initial interview, if you decide to file a complaint, the investigator will assist you.

Pre-Interview Information Form

If you are interested in beginning the complaint process, please complete the pre-interview information form below. You will be assigned an investigator who will contact you shortly.

Required*

The alleged discrimination occurred in: * Employment Housing Public Accommodation School

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

COMPLAINANT:

Full Name (including middle initial): *

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Permanent Address: *

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City: *

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State: *

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Zip Code: *

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Phone: *

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Work Phone: *

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Cell: *

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Email: *

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Date of Birth: *

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

Name: *

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Phone: *

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Address: *

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City: *

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State: *

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Zip Code: *

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Relationship: *

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

Race or Color

National Origin

Ancestry

Place of Birth

Religion

Age

Disability

Pregnancy

Equal Pay Issue

Sex

Retaliation

Familial Status (Housing only)

Sexual Orientation

Sexual Harassment

PLEASE PROVIDE the following:

Date of Incident/Discrimination: *

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I learned about this agency by:

If charging an Employer with discrimination, are you currently employed with them? * Yes No Does Not Apply

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If charging a Housing Provider with discrimination, are you facing eviction? Yes No Does Not Apply

NAVIGATION

Laws

Title VII of the Civil Rights Act of 1964
Metro's Rules & Regulations
Fair Housing Act
Equal Pay Act of 1963
Civil Rights Act of 1991
Fort Wayne City Ordinance
Age Discrimination in Employment Act of 1967
Americans with Disabilities Act Amendments Act 2008