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Instructions for Completing the Complaint Form

Please read these instructions BEFORE you begin answering the questions on the complaint form.

If possible, TYPE your answers. If typing is not possible, then print your answers in INK. Do not write in longhand. Use black ink, and no pencil.

Q. #1 First Name, Middle Initial, and Last Name

example: Mary J. Doe

Q. #2 Home Address

Q. #3 Home Telephone Number

Q. #4 National Origin is your birth Country or ancestry. (It is not necessary to give us City and State where born.)

Q. #5 Basis is the personal characteristic which accounted for the alleged discrimination.

Q. #6 Area is where the alleged discrimination occurred.

Q. #7 Full legal name and address of the business or company that is responsible for the alleged discrimination.

example: Queen Burgers, Inc.

Q. #8 What does the company make? Or what service does the company provide?

Q. #9 Full legal name, address, and telephone number of the "parent" company or corporate office

Q. #10 Estimate the total number of employees at all locations.

Q. #11 Did you file a complaint alleging discrimination with another anti-discrimination agency regarding these same set of facts before you contacted the Iowa Civil Rights Commission? If so, what agency and when?

Q. #12 The Equal Employment Opportunity Commission (EEOC) is a federal agency that enforces federal employment anti-discrimination laws. If your complaint can be cross-filed with the EEOC, it will be cross-filed automatically unless you protest and tell us in writing: "Don't cross-file." Cross-filing preserves your rights under federal anti-discrimination law.

Q. #13 Legal name and job position of person who discriminated against you

example: Bill A. Jones, District Manager

Q. #14 Legal name and job position of person who harassed you

example: Susan K. Smith, Supervisor. Use her name in the narrative and give examples of the harassment.

Q. #15 The last date something negative happened to you usually triggers the filing limitations period. Complaints must be filed with the Iowa Civil Rights Commission within 300 days of that date. 

Include what happened on that date.

example: not hired or terminated or last time harassed

"the particulars of your complaint"

Please first write your narrative on a separate sheet of paper and then work on it until you are satisfied. Then transfer it to the complaint form. Keep your narrative as brief as possible. Use only the space provided on page.

In your narrative, be sure to provide the following information:

1. What happened?

2. When did it happen?

3. Who made the decision for the company?

4. What makes you think the decision or action was discriminatory?

5. Why do you believe that your race, age, sex, etc. was a factor in the company's decision?


A. I was terminated by Mark B. Jones, my supervisor, on May 15, 1998. I believe I was fired because of my age. I am 67 years old. Younger co-workers who had less experience and inferior work records were retained.

B. Since my date of hire, June 12, 1996, I have been harassed by Jim Smith, a supervisor, because of my race. He calls me names and criticizes my work constantly. He treats me very differently from my white co-workers. I am African American. I believe he is treating me differently because of my race.

C. On June 15, 1998, I applied for a sales position at the company's downtown location. I was qualified for the position. I had 10 years of experience. A male with no experience was selected over me. I am female. The company has approximately 35 sales persons. Only 5 are female. I believe my sex was a factor in the company's decision not to hire me.

D. On May 28, 1998, I learned that I was being paid less than my male co-workers. I started working at the company on June 1, 1997. I make $7.00 per hour. My male co-workers make $7.50 per hour. We all do the same job. We have the same duties. I am female. I believe that I am being paid less because of my sex.
Remember to be brief. Include just the key facts. Later you will be asked to provide additional information. Take one last look at your complaint. Make sure you answered each question.