Indicates required field Your Information First name Last name Email address I do not have an email address Phone number I do not have a phone number Work phone number Address Address line 1 Address line 2 City State Zip code Incident Information What is the basis of the alleged discrimination, harassment or retaliation? Select all that apply Color Disability National Origin / Ancestry Race Limited English Proficiency (LEP) When did the alleged discrimination, harassment or retaliation occur? Where did the alleged discrimination, harassment or retaliation occur? Please explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. Have you filed this complaint anywhere else? e.g. Maryland Commission on Civil Rights, Department of Justice, etc. Yes No Where and when did you file this complaint? Offending Agency Information Name of agency complaint is against Contact person Title Phone number Additional Information You may attach any written materials or other information that you think is relevant to your complaint? Comments Accessibility Please outline any disability accommodations necessary for you to participate in the complaint proccess e.g. interpreter services, audio instructions, etc. Affirmation By signing my name below, I affirm that I have read the above charge(s) and that it is true to the best of my knowledge, information and belief. Signature Print a copy of this form for your records.
