DISCRIMINATION REPORT FORM
Please read the policy for assistance:

After completing this form please print out (2 pgs) and return to:

    NAAWP Florida Chapter Inc.
    P.O. Box 37504
    Jacksonville, FL 32236
Directions: This is a preliminary discrimination report form which is to be completed by individuals who believe they have been discriminated against based on race, gender, religion, natural origin, physical handicap or have otherwise been subjected to sexual harassment and wish the NAAWP Florida Chapter Inc.to conduct an investigation of the alleged events. NAAWP Florida Chapter Inc.will assist individuals in their efforts to resist discrimination though any means legally available with regard to federal, state and local statutes and constitutions. You should fill out this form in detail and with as complete information as is available. Also, please attach any documentation available which supports your claim of discrimination.

Name of Complainant:        Gender:  Male Female

Ethnic Origin:                 Handicapped:  YesNo

Physical Address: 

City:  State:  Zip: 

Describe the alleged incident or events in the box below:
Date of incident:   

Is this a single occurrence of discrimination or an ongoing practice of discrimination:

YesNo

If this is a work related incident please fill out the information below:
Employer: 

Employer's Address: 

City:  State:  Zip: 

Your Job Description: