Data Name |
Data Type |
Options |
Mr | Text Box | |
First name | Text Box | |
Last name | Text Box | |
Title | Text Box | |
Email | Text Box | |
Phone (mobile) | Text Box | |
Home address | Text Box | |
City | Text Box | |
State | Text Box | |
Postcode | Text Box | |
Gender | Text Box | |
Ms | option |
Part A - Your Details (Your complaint)
Title
|
Mr | option |
Ms
|
Mrs | option |
Mr
|
Miss | option |
Mrs
|
Dr | option |
Miss
|
Prof | option |
Dr
|
Other | option |
Prof
|
State/Territory | dropdown | - None - |
Yes | option |
Would you like a copy of your complaint emailed to you?
|
No | option |
Yes
|
Yes | option |
Do you require assistance to participate in the complaint process?
|
No | option |
Yes
|
Yes | option |
Are you making this complaint on behalf of someone else (the aggrieved person)?
|
No | option |
Yes
|
Ms | option |
No
Title
|
Mr | option |
Ms
|
Mrs | option |
Mr
|
Miss | option |
Mrs
|
Dr | option |
Miss
|
Prof | option |
Dr
|
Other | option |
Prof
|
Yes | option |
Do you have a legal representative or advocate?
|
No | option |
Yes
|
Ms | option |
No
Title
|
Mr | option |
Ms
|
Mrs | option |
Mr
|
Miss | option |
Mrs
|
Dr | option |
Miss
|
Prof | option |
Dr
|
Other | option |
Prof
|
State/Territory | dropdown | - None - |
Organisation | option |
Next Step
Part B - Who is the complaint about?
Who is the complaint about?
|
Individual | option |
Organisation
|
State/Territory | dropdown | - None - |
Ms | option |
(eg employer, landlord, provider of good and services)
Title
|
Mr | option |
Ms
|
Mrs | option |
Mr
|
Miss | option |
Mrs
|
Dr | option |
Miss
|
Prof | option |
Dr
|
Other | option |
Prof
|
State/Territory | dropdown | - None - |
Yes | option |
(eg employer, landlord, provider of good and services)
Do you want to add another respondent?
|
No | option |
Yes
|
Organisation | option |
No
For?
|
Individual | option |
Organisation
|
2nd Respondent's State/Territory | dropdown | - None - |
Ms | option |
(eg employer, landlord, provider of good and services)
Title
|
Mr | option |
Ms
|
Mrs | option |
Mr
|
Miss | option |
Mrs
|
Dr | option |
Miss
|
Prof | option |
Dr
|
Other | option |
Prof
|
2nd Respondent's State/Territory | dropdown | - None - |
I have been discriminated against because of my: | checklist |
(eg employer, landlord, provider of good and services)
Next Step
Please provide as much information as possible about the organisation or person who your complaint is about. It is not necessary to complete all of these fields, but if it is not possible for us to identify who you are complaining about, we may |
Age | checklist |
I have been discriminated against because of my:
|
Disability | checklist |
|
Association to a person with a disability | checklist |
|
Use of an assistance animal or disability aid or because I have a carer | checklist |
association to a person with a disability
|
Sex | checklist |
use of an assistance animal or disability aid or because I have a carer
|
Pregnancy | checklist |
|
Marital or relationship status | checklist |
pregnancy
|
Family responsibilities | checklist |
|
Sexual orientation | checklist |
family responsibilities
|
Gender identity | checklist |
|
Intersex status | checklist |
|
Race (including colour, national origin, descent, ethnicity and immigrant status) | checklist |
|
Trade union activity (employment only) | checklist |
|
Criminal record (employment only) | checklist |
trade union activity (employment only)
|
Religion (employment only) | checklist |
|
Political opinion (employment only) | checklist |
|
Social origin (employment only) | checklist |
political opinion (employment only)
|
I believe I have been sexually harassed | checklist |
I believe
|
I believe I have experienced racial hatred | checklist |
I believe I have been sexually harassed
|
I believe my human rights have been breached by a Commonwealth government agency | checklist |
I believe I have experienced racial hatred
|
I believe I have been victimised because I made, or tried to make, a complaint about discrimination | checklist |
I believe my human rights have been breached by a Commonwealth government agency
|
Please check this box if you intend to email the Commission supporting information. | checklist |
Describe the event(s) that you want to complain about. We need to know what you say happened, where it happened and who was involved. Please give us all the dates and other details you can remember. If you are complaining about employment, please tell us when you commenced employment, your job title and whether you are still employed.
Supporting Information
Please |
Upload document | file | |
Yes | option |
Have you complained about this to another organisation?
|
No | option |
Yes
|
Yes | option |
Were you referred to us by another organisation?
|
No | option |
Yes
|