NAACP Incident Report Form
This is the Eugene Springfield NAACP Incident Report form. Please complete this form in order to lodge a complaint against an organization or discrimination. The NAACP cannot provide legal advice or supply you with an attorney. We can however make recommendations and referrals to legal and social justice professionals and advocate on your behalf.
Email address *
Are you a member of the NAACP *
First Name *
Your answer
Last Name *
Your answer
Address (street, city, state, zip)
Your answer
Telephone # (where we can reach you) *
Your answer
Please provide any information you feel comfortable sharing about yourself. (race, gender, ethnicity, employment and housing status, etc.)
Your answer
Do you currently have an attorney? *
If so, what is your Attorney's Name?
Your answer
Attorney contact (email or phone)
Your answer
Has a lawsuit been filed?
If so, when?
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/
DD
/
YYYY
Have you filed a complaint with the EEOC?
If so, when?
MM
/
DD
/
YYYY
Have you filed a complaint with Fair Employment & Housing?
If so, when?
MM
/
DD
/
YYYY
Please select the type of organization you are filing a complaint about an incident against? (check all that apply) *
Required
Type of discrimination? (select all that apply) *
Required
Please tell us about the incident(s) *
Your answer
Were there any witnesses? *
If yes, and you have information please provide name and contact info for all witnesses.
Your answer
By whom were you discriminated? (If you have it, please provide name, contact info, description of all people involved) *
Your answer
Where did the incident(s) take place? (please provide address and dates if multiple incidents) *
Your answer
What was the effect or impact of the discrimination against you? *
Your answer
To date, what actions have you taken to resolve this issue? *
Your answer
Have you contacted any other organization to file a complaint or follow up? *
If yes, what actions have been taken by the other organizations or agency to respond to your complaint? What is the name of the person who took the action?
Your answer
What would you like the NAACP to do?
Your answer
Do you agree with the following statements? *
Affirmation and Disclaimers
I affirm that the statements that I have made in this form are accurate and true to the best of my knowledge and belief. I hereby request the assistance of Unit #1119 of the NAACP in seeking a remedy to the situation described by me. I hereby authorize the officers of Unit #1119 to have access to information and documents which are relevant to my claim of discrimination described.
I understand that once a referral has been made to a volunteer, community agency or private attorney, Unit #1119 WILL NOT BE RESPONSIBLE for handling this matter. I further understand that by submitting this document I am agreeing to hold Unit #1119 of the NAACP harmless for any and all damages arising as a result of my case being mishandled, negligently or improperly handled in any way.
NON-RETALIATION REQUIREMENTS
Section 704(a) of the Civil Rights Act of 1964 (as amended), Section 4 (d) of the Age Discrimination in Employment Act of 1967, (as amended), and various other civil rights laws make it an unlawful employment practice for an employer, employment agency or labor organization to discriminate against employees, applicants for employment, members or applicants for membership, because the employees, member or applicant has opposed an unlawful employment practice, made a charge, testified, assisted, or participated in any manner in an investigation, proceeding or hearing.
COMPLETION OF THIS FORM
Completing this form does NOT constitute filing an official complaint with a legal authority. At this time, unit #1119 of the NAACP is seeking information to assist you concerning this complaint. Please contact us at legal@naacplanecounty.org for more information.
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