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Harford County Human Relations Complaint Form

2. 

4. Harford County Human Relations Complaint Form
   Under provision of the Harford County Charter 95 (Discriminatory Practices)

   Under provision of the Harford County Charter 95 (Discriminatory Practices)

6. COMPLAINANT INFORMATION

8. First Name

9. Last Name

11. Occupation/Organization

13. Phone Number

14. Email Address

16. Address

18. City

19. State

20. Zip Code

22. Mailing Address

24. City

25. State

26. Zip Code

28. RESPONDENT INFORMATION

30. First Name

31. Last Name

33. Occupation/Organization

35. Phone Number

36. Email Address

38. Address

40. City

41. State

42. Zip Code

44. Mailing Address

46. City

47. State

48. Zip Code

50. ALLEGED DISCRIMINATORY INCIDENT

52. Basis for Discrimination

    (Please check all that apply)

    1. Race
    2. Creed
    3. Color
    4. Sex
    5. National Origin
    6. Age

    1. Occupation
    2. Marital Status
    3. Political Opinion
    4. Personal Appearance
    5. Mental Handicap
    6. Physical Handicap
54. Discriminatory of Wrongful Practice Involving:

    (Please check all that apply)

    1. Administration of Justice
    2. Education
    3. Employment
    4. Governmental Services

    1. Housing
    2. Public Accommodations
    3. Other
56. If other, please specify

58. Date & Time of Incident
    Date & Time of Incident

    Date & Time of Incident

60. Please give the name, address and telephone number of any other agency you contacted about this complaint.

62. Name of Agency

64. Address

66. City

67. State

68. Zip Code

70. Phone Number

71. Email Address

73. How did you hear about the Office of Human Relations?

75. Did anyone witness the events you described above? If yes, please list their contact information, if possible.

    1. Yes

    1. No

77. First Name

78. Last Name

80. Address

82. City

83. State

84. Zip Code

86. Phone Number

88. Describe what happened

90. Parties to complaints may voluntarily resolve their differences without an extensive investigation or expenditure of resources by participating in a mediation process. Are you interested in participating in such a process?

    1. Yes

    1. No

92. By submitting this form, I do hereby attest that the information in the foregoing complaint is true and correct to the best of my knowledge.

Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

* indicates a required field