Home | CVAD-Grants Manual | Chapter 24 Civil Rights/Complaint Process | Discrimination Online Complaint Form

Discrimination Complaint Form

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The purpose of this form is to assist you in filing a discrimination complaint with the Crime Victim Assistance Division in connection with one of its funded organizations or services. You can complete this form for yourself or on behalf of another person.

Submitter Information

Please fill out the first part of this form about you, the person submitting this form.

Submitter Name (First and Last):

Submitter Street Address:

Submitter City:

Submitter State:

Submitter Zip Code:

Email Address:

Home Telephone:

Work Number:

Other Phone Number:

Person(s) discriminated against, if different from above

Is this discrimination complaint about you:

Yes, this complaint is about me.

No, this complaint is not about me.

Agency and department or program that discriminated

Department/Program Name:

Department/Program Address:

Department/Program City:

Department/Program State:

Department/Program Zip Code:

Department/Program Home Telephone:

Department/Program Work Telephone:

Department/Program Other Phone Number:

**Please note: The final report produced at the completion of the complaint investigation will become public record. All personally identifying information for the victim/survivor would be withheld and/or redacted per federal and state confidentiality requirements.