Nondiscrimination Complaint Form | Department of Public Health & Environment

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Person(s) filing the complaint

(attach additional documents as necessary at the end of this form)

Name, address, and email

Name (type in your full name)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Alternate Phone Number (optional)

email

Additional Information

Person(s) or community discriminated against

(provide details of the individual or community discriminated against; attach additional documents as necessary at the end of this form)

Name of individual or community discriminated against

Relationship to that Person or Community:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Alternate Phone Number (optional)

Email Address (if available)

Additional Information