Report Discrimination Regarding Your Photo ID
Please select one of the choices
I am reporting an incident that happened to me
I am reporting this incident on behalf of another
I am reporting this for an incident that happened to me and others
Name
Address
County
State
Zip Code
Age
Gender
Male
Female
Country where Incident occured
Telephone Number
Cell Phone Number
Email
Name and Address of Office Where the Incident Occurred
Date Of Incident
Please Describe the Incident
Whom did you speak with (Please List all Names & Job Position)?
Did the person give you any options?
Did you ask to speak with a supervisor?
Yes
No
If yes what did the supervisor say?
What was the persons' demeanor i.e. how did they treat you?
Your comments on how the incident made you feel