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City of Kansas City, Mo.
Human Relations Department
 
Employment Discrimination Complaint Intake Form
Civil Rights Enforcement Division 
 
Instructions:
A complaint of discrimination must be filed within 180 days of the alleged act of discrimination. Upon receipt, this form will be reviewed to determine whether HRD can investigate this complaint. ANSWER ALL QUESTIONS that pertain to your situation, as completely as possible, and attach additional pages if needed to complete your response(s). If you do not know the answer to a question, answer by stating "not known". If a question is not applicable to your situation, write "n/a".

I understand that this questionnaire is not a complaint form and that I have not yet filed a complaint of discrimination. I understand that HRD will review this form and if the information constitutes a basis for filing a complaint, a complaint will be mailed to me for signature. In order to preserve my rights, the signed complaint will need to be received at HRD within 180 days of the alleged act of discrimination. I understand that a copy of the complaint form I sign will be sent to the employer, union or employment agency and will be the basis for the HRD investigation.
 
How did you hear about the City of Kansas City, Missouri's Human Relations' Civil Rights Division?
If newspaper, what publication?

 
Personal Information
* Personal Last Name:
* Personal First Name:
Personal Middle Initial:
* Personal Street Address:
* Personal City:
* Personal State:
* Personal Zip:
* Date of Birth:
Personal Email:
* Personal Phone:
Contact Information (Someone who does NOT reside with you and will know how to contact you.)
* Contact Last Name:
* Contact First Name:
Contact Middle Initial:
Contact Street Address:
Contact City:
Contact State:
Contact Zip:
* Contact Phone:
Contact Email:
* Contact Relationship to Complainant:
 
 Please note: If any of the above information should change, please notify the Human Relations
 Department immediately at 816-513-1836. Failure to do so could mean your case may be closed.
Filing Information
Have you filed this complaint with any other agency?
If yes, which agency and on what date did you file the complaint?
If you have been assigned a case worker, please provide their contact information below.
Last Name
First Name
M.I.
Street or Mailing Address
Apt. or Unit #
City
County
State
ZIP
Home Phone Number
Work Phone Number
Cell Phone Number
E-mail Address
Respondent Information (The Respondent is the person, agency, company, etc., that you are complaining against.)
* Respondent Name:
* Street Address:
* City:
* State:
* Zip:
* Phone Number:
No. of Employees:
Name and Title of Chief Executive:
Employment Information:
Date Hired:
Most Recent Job Title:
Salary:
Supervisor's Name Title:
Basis of Discrimination
 
You believe that the action(s) taken against you was(were) because of your:
COMPLAINANT STATEMENT (The complainant is the person who believes that he/she has been discriminated against.)
 
What did the respondent do? List each action that you believe was discriminatory. For example: I was terminated, not hired, not promoted, disciplined more harshly, retaliated against, etc. Be specific regarding who, what, when and where. Then state why you believe that the treatment you received was because of the basis that you checked above.

Add all pertinent information. If you have relevant documents that are saved as files on your computer, please attach(upload) them at the end of this form. Please mail in any other documents that are not able to be uploaded and reference those documents in the following entry field.
If applicable, provide the names and job titles of persons who you believe were treated more favorably than you because you belong to the category checked above. Include the category (race, gender, age, etc.) of the person (s) you are comparing yourself to
Name and Address:
Category:
Name and Address:
Category:
Name and Address:
Category:
Harassment (Sexual or Racial)
If your complaint involves sexual harassment or racial harassment, please state whether or not you reported it to management, who in management you reported to, and what was the response
Respondent's response?
What reasons were give by your employer for the actions taken against you?
Witness Information
If known, please provide the names, home addresses and telephone numbers of persons who may have first hand knowledge of what happened to you or who may have seen or experienced similar treatment.
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Home Phone:
What information can this witness provide?
What information can this witness provide?
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip:
Home Phone:
What information can this witness provide?
Refusal Information
If refused a job, promotion, transfer, etc., please complete as many as you can:
Title of job sought:
How did you know about the job?
When and to whom did you submit your application?
Who got the job, promotion, transfer, etc.?
What reason was given for your denial?
Did you apply verbally or by written application?
Remedy
What remedy relief are you seeking?
Attach any related files Here:
File 1:
File 2:
File 3: