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Discrimination Complaint Form Template

Efficiently Addressing Discrimination Issues with Our Template

If you need a reliable way to report instances of discrimination, look no further. Our discrimination complaint form template is tailored for individuals who want to document their experiences clearly and effectively. This form aids in raising concerns with your HR department, ensuring compliance with policies and creating a record for follow-up. Enjoy the benefits of easy customization, improved reporting efficiency, and WCAG-aligned accessibility, making it usable for everyone. Explore the live template to get started.

Use this Template (FREE) Live Preview
Your full name
Email address
Phone number
Preferred contact method
Email
Phone
No preference
Name of person(s) or organization
Type of person or entity
Please Specify:
Your relationship to them
Employee
Job applicant
Contractor
Customer or client
Student
Tenant
Patient
Member of the public
Other
Please Specify:
Date of most recent incident
How many times has this happened?
One time
A few times
Many times
Ongoing
Not sure
Location details (e.g., address, site, city)
Describe what happened in your own words
Where did this occur?
Please Specify:
What protected characteristics do you believe were a factor? (Select all that apply)
Please Specify:
If you selected Other, please specify
Were you subjected to retaliation (e.g., punishment or threats) after reporting or resisting the behavior?
Yes
No
Not sure
Were there any witnesses?
Yes
No
Not sure
Witness names and contact information (if known)
Briefly list any evidence and how we can access it
Do you have any evidence you can share (e.g., emails, messages, photos)?
Yes
No
Not sure
How has this affected you (e.g., emotional, educational, financial, employment, housing)?
If yes, please provide details (who you reported to, dates, and any outcome so far)
Have you reported this to the respondent or any other organization or authority?
Yes
No
What outcomes would you like? (Select all that apply)
Please Specify:
If you selected Other, please describe
May we share your complaint with the respondent to try to resolve it?
Yes
No
Ask me first
Age band
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
If you prefer to self-describe your gender, please specify
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Type your full name as signature
Signature date
I confirm the information provided is accurate to the best of my knowledge
Yes
No
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Paper art illustration depicting a discrimination complaint form template for FormCreatorAI article

When to use this form

Use this form when someone experiences unfair treatment tied to a protected trait and you need a clear, documented report. It helps employees, managers, and HR capture facts, dates, and evidence so you can act quickly and fairly. Examples include biased hiring or promotion decisions, slurs or harassment, denial of reasonable accommodation, or unequal pay. If you are not ready to share your name, you can start with an Anonymous complaint form. For broader workplace issues, an Employee grievance form may be better. After submission, route details into your HR Investigation form to manage interviews and outcomes. For interpersonal friction not tied to a protected class, consider a Hurt feelings complaint form.

Must Ask Discrimination Complaint Questions

  1. Which protected characteristic do you believe motivated the conduct (e.g., race, color, religion, sex, gender identity, sexual orientation, pregnancy, national origin, age, disability), and why?

    This frames the issue as discrimination, not general conflict, and ties facts to policy and law. If your concern is not about a protected trait, a Grievance form may be more appropriate.

  2. What exactly happened? Describe words, actions, or decisions, and attach any evidence (emails, messages, photos).

    Clear, factual detail lets reviewers assess severity and pattern. Specifics reduce bias and help compare similar cases.

  3. When and where did it occur? List dates, times, locations, and whether it is ongoing.

    A precise timeline helps preserve evidence and identify jurisdiction. It also guides who to notify and which deadlines apply.

  4. Who was involved or witnessed the incident? Include names, roles, and how to contact them.

    Identifying parties enables impartial interviews and corroboration. This supports a consistent process and faster resolution.

  5. What impact has this had on you or others, and what outcome are you seeking?

    Impact shows risk and urgency, while your requested outcome shapes remedies such as training, discipline, or accommodation. Clear goals help set expectations and measure closure.

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