Full Text
Form 1A Navajo Nation Human Rights Commission P.O. Box 1689 Window Rock, Navajo Nation (Arizona) 86515 Phone: (928) 871-7436 Fax: (928) 871-7437 COMPLAINT FORM For Official Use Only Media Packet Intake No.: Cross Ref. Docket No.: Cross Ref. Federal, State, City or Municipal Agency No.: Letter sent out: Person Making the Complaint Today’s Date: Your Name: Your Mailing Address: City / State / Zip: Daytime Phone: Evening Phone: Chapter Name Your Residence: E-mail Address: *Draw a map to locate your residence on the following sheet>>>> Who else can we reach if you are unavailable? Contact’s Name: Relation: Daytime Phone: Evening Phone: Contact’s Name: Daytime Phone: Evening Phone: Contact’s Name: Daytime Phone: Evening Phone: Who was present when the incident happened? Witness’ Name: Daytime Phone: Evening Phone: Witness’ Name: Daytime Phone: Evening Phone: ---PAGE BREAK--- Form 1A *Draw a map to locate your residence on this sheet. ---PAGE BREAK--- Form 1A Complaint Information 1. What happened to you? Detail as much as possible how were you discriminated against in chronological order of events. Please take as much time and space you need. Be sure to tell us what happened (including the date and time of the incident), who discriminated against you and who were present (family, friends or others who may have witnessed the incident. Also, please note anything that anyone said. ---PAGE BREAK--- Form 1A 2. The type / kind of discrimination. ❏ Employment ❏ Housing ❏ Civil Rights Violation/Hate Crime ❏ I Don’t Know ❏ Other: 3. On what basis were you discriminated against? ❏ Race ❏ Color ❏ National Origin/Ancestry ❏ Religion ❏ Gender Identity ❏ Age ❏ Sexual Orientation ❏ Sexual Harassment ❏ Mental Disability ❏ Physical Disability ❏ Public Accommodations ❏ I Don’t Know ❏ Other: 4. Who do you believe discriminated against you? Name: Address: City / State / Zip: Phone: Please select the department/agency, employer, organization, and/or person which you are filing the complaint against: ❏ Department/Agency ❏ Employer ❏ Organization ❏ Person ❏ Other: 5. When and where did the discrimination occur? Date(s) of Incident: Address: City / State/ Zip: Location, if address is unavailable: 6. Do you currently have an Attorney working on your behalf? ❏ Yes (If yes, please answer the following questions) ❏ No A. Attorney’s Name: B. Attorney’s Address: C. Attorney’s City / State / Zip: D. Attorney’s Telephone No.: E. Has a lawsuit being filed on your behalf? ❏ Yes ❏ No If yes, what is the file date? Case Number: ---PAGE BREAK--- Form 1A City/State: Court Location: F. Does your attorney know you are filing this complaint with the Office of the Navajo Nation Human Rights Commission? ❏ Yes ❏ No 7. Have you filed a complaint with a Federal, State, City or Municipal Agency? ❏ Yes (If yes, please answer the following questions) ❏ No ❏ Does Not Apply A. If yes, Agency: File Date: City/State: Case number: Phone: A right to sue letter? ❏ Yes ❏ No IN ORDER TO BEGIN THE NECESSARY STEPS TO RESOLVE THE COMPLAINT, THE COMPLAINT FORM MUST BE ENTIRELY COMPLETE. YOUR ACTIVE PARTICIPATION IS ALSO NECESSARY THROUGHOUT THE PROCESS. The information I, (Print Name), provided is true and completed to the best of my knowledge. I do hereby authorize the Navajo Nation Human Rights Commission to investigate my complaint and to take the steps necessary to resolve the complaint. Signature Date Mail Completed Complaint Form to: NAVAJO NATION HUMAN RIGHTS COMMISSION P.O. Box 1689 Window Rock, AZ 86515 ---PAGE BREAK--- Form 1A NAVAJO NATION HUMAN RIGHTS COMMISSION AUTHORIZATION & RELEASE OF PROTECTED INFORMATION I, request and authorize you to furnish to the and/or DNA-People’s Legal Services, Inc. the following information, records or reports: The purpose of this request is: The information requested includes any information protected by the Privacy Act of the 1974, 5 U.S.C. §552A (1976), or other state or federal law, including the United States Constitution and any state constitution. A photo static copy of this authorization shall be considered effective and valid as the original. This authorization is valid for one year after the date appearing on it. Client’s Signature Date Translator Certification (if applicable) I, can read, write and speak the English language and can speak the language fluently. I certify that I have correctly translated the foregoing to the above-name client and that he/she has affirmed he/she agrees to it. Client’s Signature Date