Online Discrimination Complaint Form

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Please fill out this form to allow the Greater Indianapolis NAACP to review your complaint and determine what steps, if any, we can take to assist you. Your complaint will be catagorized, processed & filed and we will be back in touch to procede if we determine action on the part of our branch is warranted. Submitting this form give us the authorization to share with our State and National NAACP Offices.

The Greater Indianapolis Branch NAACP will refer complaints alleging employment discrimination to an appropriate agency for official investigation, i.e., EEOC, Indiana Civil Rights Commission, and monitor the agency's work on all cases referred by the NAACP. Completing this form does not constitute filing an official complaint with a legal authority.

To the extent resources allow, the Greater Indianapolis Branch NAACP may provide other supportive assistance to the complainant. In virtually all instances of employment discrimination, complainants will lose their right to any form of legal remedy if they do not file a complaint with the EEOC within 180 days of the event of the alleged discriminatory conduct and or act. Since Indiana has a civil rights commission, then this time period is expanded to 300 days. If there is any doubt, file within 180 days just to be sure.

Please answer all questions and be as specific as possible.

Email *

1. Are you an NAACP member? *

Yes

2. Name *

3. Mailing Address *

4. City *

5. State *

6. ZIP *

7. Phone number where you can be reached *

8. Your Race *

African American/Black

Hispanic

Asian/Pacific Islander

White

Native American

Mixed Race

Other:

9. Gender *

Male

Female

Non-binary

Prefer not to say

10. Age *

11. Who discriminated against you? If possible, give the name, employer and address of the individual(s) involved.

12. TYPE OF DISCRIMINATION

Please check at least one box below to indicate the type of discrimination covered by your complaint and the context where it occurred.

Public Accommodation Discrimination

Denial or improper treatment (in restaurants, hotels, stores, hair cutting, etc.)

Racial profiling

Housing discrimination

Clear selection

Criminal Law/Policing/Courts

Racial profiling

Unlawful arrest (battery, unreasonable use of force)

Other:

Clear selection

Employment Discrimination (Note: You may lose your right to any form of legal remedy if you do not file a complaint with the Equal Employment Opportunity Commission (EEOC) within 180 days of the alleged discrimination. Filing a complaint with the NAACP does not constitute filing with the EEOC or Indiana Civil Rights Commission.)

Race

Sex (gender discrimination)

Sexual Orientation

National Origin/Ethnicity

Age

Religion

Education

Medical

Disability

Veteran's Status

Retaliation

Whistle Blowing (Employees who blow the whistle regarding fraud or misconduct)

Wage and Hour (Failure to pay full amount of compensation owed)

Clear selection

Consumer Fraud/Discrimination

Leasing: auto or equipment (excessive fees, late fees, hidden fees)

Credit card issues (excessive fees, late fees, hidden fees)

Mortgage issues (excessive fees, late fees, hidden fees, foreclosure)

Insurance issues (excessive fees, late fees, hidden fees)

Predatory lending (discrimination against minorities in lending)

Deceptive billing practices (e.g., cell and telephone charges)

False and misleading advertising

Defective products

Clear selection

YOUR STORY

13. Description (please describe the incident(s) in detail and why you feel you were a victim of discrimination). Tell us as much as you can. Who discriminated against you? Why do you believe it was because of your race, color, religion, national origin, sex, age or other characteristic? *

14. What are you asking the NAACP to do for you? *

Investigate

Advocate to change policies or conditions

Obtain monetary damages (NOTE: The NAACP cannot represent you in a lawsuit to obtain monetary damages, but we may refer you to others who can review your case.)

Other:

15. Have you retained an attorney to represent you? *

Yes

16. If you have retained an attorney, please provide their name, phone number and email address. By providing their information, you give the NAACP permission to contact them.

17. Have you filed a complaint with any government agency or a grievance with your union? (Yes or No)

If yes, which one(s)?

LIABILITY RELEASE

The Greater Indianapolis NAACP is an all-volunteer organization. We may refer your complaint to the appropriate agency for official investigation. We monitor all cases that we refer to a government agency. Completing this form does not constitute filing an official complaint with a legal authority.

To the extent resources allow, we may offer other support to you as a complainant.

18. Release of Liability (check both boxes to allow us to proceed) *

I affirm that the statements I have made above are accurate and true to the best of my knowledge and belief. I hereby request the assistance of the NAACP in seeking remedy of the situation described above. I hereby authorize the officers and executive committee of the NAACP to have access to information and documents which are relevant to my claim of discrimination described above.

I understand that once a referral to a volunteer, community agency or private attorney has been made, the NAACP WILL NOT BE RESPONSIBLE for handling this matter. In fact, I further understand that by signing this document, I am agreeing to HOLD THE NAACP harmless of any and all damages arising as a result of my case being mishandled, negligently handled or improperly handled in any way.

Required

19. Signature (Required): Please enter your full name below, to provide a digital signature. Without a signature, we cannot process your request. *

A copy of your responses will be emailed to the address you provided.

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