CITY OF BROCKTON Department of Human Resources Office of Diversity, Equity and Inclusion Discrimination Intake Form This form is for intake purposes only and does not indicate that the Department of Human Resources for the City of Brockton has accepted this report as a formal request for evaluation. The DEI Manager or the Director of Human Resources will be in touch with you to follow up on your submission. Please note that the Department of Human Resources only has jurisdiction pertaining to employees in the City of Brockton, and can only evaluate alleged discriminatory acts that occurred within 180 days of the date that the evaluation request has been submitted. If you prefer not to use this form, either the DEI Manager or the Director of Human Resources will conduct an intake with you over the phone or in person, by appointment. Your Information1. First Name(Required) 2. Last Name(Required) 3. Primary Phone Number(Required) 5. Email(Required) 6. Additional Contact Information 7. Who referred you? How did you hear about our office? 8. Please check off the appropriate options below if you believe they played a role in your experience(Required) Race Color Disability Source of Income National Origin Marital Status Gender Religion Age Family Status Retaliation Sex Sexual Orientation Military Status Offensive Language Hate Speech Other Please Define Other 9. Why do you believe you were discriminated against?(Required)10. Who do you believe discriminated against you?(Required)11. Please descibe in detail what happened. You may also upload any supporting documents at the end of this form(Required)12. When did this discrimination happen (Date)?(Required) MM slash DD slash YYYY 13. Address where the discrimination happened?(Required)14. If you'd like, please upload any supporting documentationAccepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.One file only, please. File size limit is 10MB. Image files or PDF only.*Please only send 1 item, either PDF or image file, less than 10MB. If you need to send more, or larger files please send them to [email protected] and title with "First Name, Last Name, Discrimination Intake Form documents". Demographic Information Entering information helps us do a better job tracking our efforts to fight discrimination.15. Question: What is your recial/ethnic identity? (Check all that apply)(Required) American Indian/Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Hispanic or LatinX Multi-Racial I choose not to provide this information Other Please Define Other 16. What is your gender identity? (Check all that apply)(Required) Male Female Non-binary Trans Male/Trans Man Trans Female/Trans Woman Genderqueer/Gender non-conforming Different Identity I choose not to provide this information Other Please Define Other CAPTCHA
