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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.

Information:

Date*:

First Name*:

Middle Initial:

Last Name*:

Address*:

City*:

State*:

Zip Code*:

Home Phone: -

Cell Phone: -

Work Phone: -

Email Address:

County:

Discrimination Details

What Type of Complaint is This*:

Employment
Public Accommodation
Housing
Credit
Wrongful Arrest (due to discrimination)
Other

Do you believe this action was taken against you based on*:

Race / Color Specify:
National Origin (place of birth)
Sex
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 Accomodations
Employment Agency
Law Enforcement
Other Describe:

Name of Person*:

Name of Organization*:

Telephone Number:

Mailing Address

Street Address*:

City*:

State*:

Zip Code*:

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?

Community Programs
» Human Rights

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City of Tulsa, Human Rights Department Intake Form

Community Programs» Human Rights

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Community Programs
» Human Rights