Human Rights Intake Form

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Human Rights

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City of Tulsa, Human Rights Department Intake Form

Please answer the following questions, telling us briefly why you feel you have been a victim of discrimination. The form can not be submitted unless all required fields marked with an asterick are completed. You may also download a printable PDF form and mail or fax to the Human Rights Department.


Date:*
First Name:*
Middle Initial:
Last Name:*
Street Address:*
City:*
State:*
Zip:*
Home Phone:*
Cell Phone:
Work Phone:
EMail Address:
County:

What Type Of Complaint Is This:*
	Employment
	Public Accommodation
	Housing
	Credit
	Other
	Wrongful Arrest (due to discrimination)

Do you believe this action was taken against you based on:*
	Race/Color Specify:
	National Origin (place of birth)
	Sex (This includes sexual harassment)
	Religion
	Age (Employment) Specify Date of Birth:
	Retaliation
	Familiar Status (Children under the age of 18)
	Disability

I was discriminated against by (Please check all applicable):*
	Owner
	Manager
	Employer
	Union
	Public Accommodations
	Employment Agency:
	Law Enforcement
	Other Describe:

Name of Person:*
Name of Organization:*
Telephone Number:
Mailing Address
Street Address*
City*
State*
Zip*
What action was taken against you that you believe to be discriminatory? What harm, if any, was caused to you or others in your situation as a result of the action?

City of Tulsa, Human Rights Department Intake Form

Discrimination Details