Complaint of Discrimination NOTICE: Under the California Public Records Act and other disclosure statutes, the information contained in this complaint form cannot be kept confidential.*Indicates a required field You must have JavaScript enabled to use this form. Your Information Name Street Address City/State/Zip Home Phone Work Phone Are you currently employed? Yes No If yes, what is your occupation? What is your race? - None -BlackCaucasianNative AmericanHispanicAsian/Pacific IslanderOther What is your gender? Male Female Nonbinary Are translation services required? Yes No If yes, please indicate your fluent language Name the person(s) and/or organization(s) who you feel discriminated against you Name Position (if known) Organization Street Address City/State/Zip Phone Name Position (if known) Organization Street Address City/State/Zip Phone Discrimination Details I was discriminated against in: Employment Housing Other (specify) If Other was selected, please specify here: If your charge is against a company or union, what was the number of employees or members? I believe I was discriminated against because of my (check all that apply): Race Religion National Origin Sex Age Mental/Physical Impairment Sexual Orientation Marital Status Gender Family Status Ancestry Other (please specify) If Other was selected, please specify here: Have you filed this complaint with any other agency? Yes No If yes, with what agency did you file the complaint? What was the date you filed the complaint? Have you ever filed a complaint with this office before? Yes No Do you know other individuals who feel they were discriminated against or who witnessed the alleged discriminations by the above person(s) and/or organization(s)? Yes No If yes, please list those individuals below. The City of San Diego Human Relations Commission may try to mediate your complaint, if the other party agrees to the mediation. What do you want to happen as a result of the mediation? Explain in detail how you feel you were discriminated against (include all dates relevant to the alleged discrimination that took place). You should attach any copies of documents that you believe will support your charge. Complain Support Documents One file only.2 MB limit.Allowed types: txt, pdf, doc, docx. I swear or affirm that I have read the above claim and that it is true to the best of my knowledge, information and belief. I understand that the respondent will be notified of the claim. Agreed Leave this field blank
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