This document is a complaint form that collects information about the complainant, respondent, and details of the complaint. It requests the complainant's contact information as well as optional demographic data. If the complainant is being assisted, it also collects contact information for the assisting individual or organization. The form then requests information to identify the respondent and the nature of the complainant's relationship to them. Finally, it asks the complainant to select the nature of the complaint, such as discrimination or victimization, and provide details about the incident.
This document is a complaint form that collects information about the complainant, respondent, and details of the complaint. It requests the complainant's contact information as well as optional demographic data. If the complainant is being assisted, it also collects contact information for the assisting individual or organization. The form then requests information to identify the respondent and the nature of the complainant's relationship to them. Finally, it asks the complainant to select the nature of the complaint, such as discrimination or victimization, and provide details about the incident.
This document is a complaint form that collects information about the complainant, respondent, and details of the complaint. It requests the complainant's contact information as well as optional demographic data. If the complainant is being assisted, it also collects contact information for the assisting individual or organization. The form then requests information to identify the respondent and the nature of the complainant's relationship to them. Finally, it asks the complainant to select the nature of the complaint, such as discrimination or victimization, and provide details about the incident.
This document is a complaint form that collects information about the complainant, respondent, and details of the complaint. It requests the complainant's contact information as well as optional demographic data. If the complainant is being assisted, it also collects contact information for the assisting individual or organization. The form then requests information to identify the respondent and the nature of the complainant's relationship to them. Finally, it asks the complainant to select the nature of the complaint, such as discrimination or victimization, and provide details about the incident.
This box seeks data about the complainant (if the complainant is an individual) that will be used for internal statistical purposes only. Please tick/ highlight as appropriate
This box is to be filled out if the complainant is being assisted/ represented by someone else, for example an Attorney-at-Law, a Corporate Officer or Board Member, a Trade Union representative, a Parent, Spouse or Child.
Name of Person ...................…………………………………………………………………………………
If you are complaining about three or more persons/ organisations/ bodies please continue listing them on an extra page (which you should attach to this form).
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Part C – About your complaint
Please tick/ highlight as appropriate which of the following you wish to
complain about.
[The Explanatory Notes in the square brackets are meant for general guidance only. Please contact us by telephone or in writing by letter or e-mail if you want any assistance or clarification.]
(a) □ Discrimination in:
□ Employment [This applies to the treatment of persons applying for employment (prospective employees) as well as to existing employees (where things like access to vocational training, promotions, transfers, benefits are included)] □ Education [This applies to how an educational institution selects students (subject to any existing Agreement or practice between the State and Educational Boards), and how it treats with existing students.] □ Provision of Goods and Services [This relates to the provision of goods, facilities and services to the public (whether or not for payment) and includes things like access to and use of a public place; facilities for entertainment, recreation or refreshment, transport or travel; the services of any profession or trade or of any statutory or municipal authority, and such like.] □ Provision of Accommodation [This applies to the treatment of persons seeking accommodation as well as of persons to whom accommodation have already been provided.]
Where you have been treated differently and/or unfavourably because of
one or more of the following reasons (i.e. your status): □ My sex □ My race □ My ethnicity □ My origin (this includes geographical origin) □ My religion □ My marital status □ My disability □ Some other reason (Please state):…………………………………………
(b) □ Victimisation [This applies where some sort of adverse action has been taken against you because of one or more of the following: (i.) You have made a complaint to the Commission or you have brought proceedings under any other law (or you have indicated that you intend to do so); (ii.) You have given evidence in any such proceedings (or you have indicated that you intend to do so);
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(iii.) You have made an allegation or assertion which amounts to a contravention of the Equal Opportunity Act or any other law (or you have indicated that you intend to do so)]
(c) □ Offensive Behaviour [This applies where a person does an act outside of a private place (for example, the act is done in a place to which the public have access, or in the sight and hearing of persons in a public place, but this does not include a public place of worship) which (i) Is reasonably likely in all the circumstances to offend, insult, humiliate or intimidate another person or group of persons; (ii) Is done because of the gender, race, ethnicity, origin, or religion of the other person or of some or all of the persons in the group; and (iii) Is done with the intention of inciting, gender, racial or religious hatred.]
(d) □ Other (Please state) ................................................................
Please indicate when did this happen? (Day/month/year) ……………..………......…………
Please describe what happened?
Please provide details of the events that you want to complaint about, including things like: (a) What happened; (b) Where it happened; (c) Who said or did what to you; (d) If you are complaining about discrimination, please provide the names of other persons who you feel were treated better/ more favourably than you were; (e) If you are complaining about discrimination in employment, please tell us when you began employment, whether you have been offered or have signed a contract, your job title and whether you are still employed.
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............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ .......................................................................................……………………………… …………………………………………………………………………………………………………… ………………………………………………………………………………….............……………… If you need more space to write, please continue on an extra page.
Part D – Any action(s) that you have already taken to address
your complaint
Have you tried to resolve your complaint directly with the Respondent(s)? (For example: through a report or through an internal grievance/ complaint process)
If so, you must provide details of
(a) What action you took; (b) If a report or complaint, the way it was made (orally or in writing) and the person to whom it was made; (c) The date on which you did this; (d) Any outcome (whether you were contacted, invited to a meeting and such like); and (e) Documents, correspondence, claims or responses (if any) that you sent and/or received from the Respondent(s) (please attach copies of same if possible). …………………………………………………………………………………………………………… ……………............................................................................................................. ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ 5 Equal Opportunity Commission Complaint Form – revised July 2012
Have you made a complaint about this to another Agency or Entity?
(For example: an Attorney-at-Law, a Trade Union, the Ombudsman, any Public Body/Authority [e.g. Consumer Affairs], any Regulatory Agency, any Civil Advocacy Group or any Non-governmental Organisation)
If so, you must provide details of:
(a) The Agency/ Entity to whom you made the report/compliant; (b) The date on which you did this; (c) Whether, as far as you know, the Agency/ Entity contacted the Respondent(s); (d) Any outcome; and (e) Documents, correspondence, claims or responses (if any) (i) That you sent and/or received from the Agency/ Entity and (ii) That the Agency/ Entity sent and/or received from the Respondent(s) (Please attach copies of same if possible). …………………………………………………………………………………………………………… ……………............................................................................................................. ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ...........................................................................................................................
If you need more space to answer any of the questions in this section, please continue on an extra page.
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Part E – Further information
Supporting evidence Please attach copies of any documents that may help us investigate your complaint (for example, letters, pay-slips, doctor’s certificates or references). If you cannot do this, please tell us about the documents or other evidence and how this evidence can be obtained.
If you need more space to answer any of the questions in this section, please continue on an extra page.
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Have you ever made a complaint or taken action against the Respondent(s), prior to this with respect to any other matter or issue? If so, please provide details of the date of the complaint(s), the details of the matter/issue and the outcome of same. ………………………………………………………............................................................. ...........…………………………………………………………………...................................... ............................................................................................................................ ............................................................................................................................
Have you ever filed a complaint with the Equal Opportunity Commission before? If so, please provide details of the date of the complaint(s), the Respondent(s), and the outcome of same. ………………………………………………………………………………………………….………… ……………............................................................................................................. ............................................................................................................................ ............................................................................................................................
How did you find out about the Equal Opportunity Commission? Please tick as appropriate: □ Website □ Information Session □ Reference/ word-of-mouth □ Billboard □ Brochure □ Other: ______________________ Media: □ Newspaper □ Television □ Radio □ On-line Could you indicate whether it was a: □ Report □ Advertisement □ Interview
STATEMENT OF TRUTH I certify that the information provided above is true and correct to the best of my knowledge, information and belief.
