2. 
4. CITY OF ROCK ISLAND HUMAN RIGHTS COMMISSION
6. DISCRIMINATION COMPLAINT FORM
8. COMPLAINANT INFORMATION (The complainant or the accused must reside or be located in Rock Island, IL)
10. First Name
11. Last Name*
12. Today's Date
14. Address1*
16. Address2
18. City *
19. State*
20. Zip*
22. Email Address
23. Telephone*
25. I believe that I have been discriminated against on the basis of:

    1. Race
    2. Age
    3. Gender
    4. National Origin
    5. Disability
    6. Religion
    7. Sexual Orientation
    8. Other
27. Explain selection of other:
29. Name the party you believe discriminated against you (Person/Organization/Business)?
31. Name*
33. Address1
35. City (The complainant or the accused must reside or be located in Rock Island, IL) *
36. State
37. Zip
39. Describe how and why you believe you were discriminated against? Please be as specific as possible
41. List the date(s) you believe the discrimination took place?*
43. What resolution or solution are you seeking? Once a completed complaint is received, the Commission can work with the parties involved to mediate the dispute and work toward a resolution. In some cases a complaint may be referred to the Illinois Department of Human Rights or another agency for resolution.*
45. Has a complaint been filed with any Federal, State of local investigative agency?

    1. Yes
    2. No
47. If “Yes” then complete the following:
49. Name of Agency
51. Address1
53. City
54. State
55. Zip
57. Telephone:
58. Date Filed:
59. Name of Contact:
61. I hereby affirm that the above information is true to the best of my knowledge:
63. Signature (Enter Name)*
64. Today's Date:
66. Questions call: 309.732.2999
68. Filing a complaint with the Rock Island Human Rights Commission should not take the place of filing a complaint with the US Equal Employment Opportunity Commission, the Illinois Department of Human Rights or any other federal or state agency which may address issues of discrimination. The function of the Rock Island Human Rights Commission is to provide mediation. In order to preserve your legal rights and potential remedies under various federal and state statutes, the appropriate agency or private legal counsel should be contacted particularly regarding the timing of filing a complaint.
Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field