Complaint Form

Instructions: 

These are INSTRUCTIONS to assist you in completing an Iowa Civil Rights Commission complaint form. This is NOT the complaint form, and will NOT be accepted as a complaint form. Do not provide answers to the questions below, as this will not be processed as a complaint, or included as part of your complaint.

The official complaint form in Microsoft Word and PDF formats can be downloaded from the links at below. To file a complaint, please print out the complaint form and submit it to the Iowa Civil Rights Commission.

Complaint Form in PDF format

Complaint Form in Microsoft Word format


Besides filing a complaint with the Iowa Civil Rights Commission, you may have other legal options. You may want to consult an attorney. If you need help in finding an attorney, contact the Iowa State Bar Association.

SECTION 1 • COMPLAINANT INFORMATION

This section asks you to provide identifying information that is necessary for the ICRC to file this complaint. You will be asked to provide your name, mailing address, telephone number, email address, date of birth, and your sex/gender.

You will also be asked if you have previously filed this same complaint with another government agency. The ICRC frequently cross-files complaints with other agencies, so if you have previously filed this complaint with one agency, it may not be necessary to file the complaint again with the ICRC.

SECTION 2 • DISCRIMINATION INFORMATION

This section asks you provide information about your allegations of discrimination.

Question 1: Indicate the Area(s) in which the discrimination occurred. Area describes the relationship between you and the organization you are filing against. Below are listed the Areas covered under the Iowa Civil Rights Act and enforced by the ICRC.

Employment - You were employed or applied for employment with the organization (private or public employer, temp agency, etc.);
Public Accommodation - You had or sought services from the organization (grocery store, gas station, police, etc.)
Credit - You had or sought financial services from the organization (bank, mortgage lending institution, etc.);
Education - You had or sought educational services from the organization (elementary/secondary school, college, etc.);
Housing - You had or sought housing services from the organization (landlord, realtor, resident manager, etc.).

Question 2: Indicate the Action(s) that the organization took against you. Action is the manner in which you believed you were discriminated against. Please identify all actions which you believe were discriminatory.

Question 3: This is a series of questions that asks you to indicate the Basis(es) or Reasons for the discrimination. Please identify all reasons which you believe apply.

ANSWER REQUIRED
Question 4: Provide the date of the most recent discriminatory incident that the organization took against you. An answer to this question is required, as it is needed to ensure the complaint is timely filed with the ICRC.

Question 5: If you have indicated that Employment is the Area, provide your hire date. For complaints alleging a failure to hire, provide your application date.

Question 6: If you have indicated that Employment is the Area, indicate whether you are still employed by the organization you claim discriminated against you. If not, please indicate how your employment ended.

SECTION 3 • RESPONDENT INFORMATION

This section asks you to provide information about the organization you are filing against.

Question 7: Provide the full legal name and contact information for the organization that discriminated against you.

Question 8: Provide the full legal name and contact information for the parent organization or corporate office of the organization that discriminated against you, if applicable.

Question 9: Provide the address of the physical location of where the discriminatory acts actually occurred. Do not put unrelated organizations on the same complaint form, unless one directly owns the other. If you are filing against more than one organization you need to file a separate complaint against each organization.

Question 10: Identify any individuals whom you claimed discriminated against you or harassed you. Be sure to provide job titles as well as work or home addresses. If you need to list more than two individuals please provide those names, titles, and addresses on a separate sheet of paper.

ANSWER REQUIRED
Question 11: If employment is the area, indicate the approximate number of all employees, including full-time and part-time at all employer locations. This allows the ICRC to cross-file qualifying complaints with the Equal Employment Opportunity Commission (EEOC) if a threshold number of employees is reached.

SECTION 4 • BRIEF SUMMARY OF ALLEGATIONS

This section asks you to describe the discrimination you experienced from the organization and/or individuals you are filing against. Please be sure to address each action you identified.  Ensure that your summary reflects the basis(es) you previously identified.

When writing your summary, think about the following questions:
1. What happened?
2. When did it happen?
3. Who made the decision for the organization?
4. What makes you think the decision or action was discriminatory?
5. Why do you believe that your basis (race, age, sex, etc.) was a factor in the organization's decision?

SIGNATURE REQUIRED
Your signature on the complaint form is required, and the complaint not be processed until a signature is provided.

 

Updated: 
April, 2016