Discrimination in Public Accommodation Complaint Online Questionnaire Form

 > Discrimination in Public Accommodation Complaint Online Questionnaire Form

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If you suspect you have been discriminated against in public accommodations, you can file a complaint below or call the Equal Opportunity Department Compliance and Enforcement Division voice line at 602-262-7486 or the TTY relay at 602-534-1557.

*Name: *Best time to call you:
 Daytime phone:
*Address: Evening phone:
City: State: Zip code:
E-mail address: Today's date: (mm/dd/yyyy)

Who else can we call if we cannot reach you? (Optional)

Contact's name: Daytime phone:
Best time to call: Evening phone:
Contact's name: Daytime phone:
Best time to call: Evening phone:

Why do you believe you are being discriminated against? It is a violation of the law to deny you your rights for any of the following reasons: race, color, religion, sex, national origin, marital status, age, disability, sexual orientation, gender identity or expression. For example, were you denied access or admittance to a place of public accommodation such as a restaurant, theater, etc? Were you refused service, or did you experience diminished service? Were you charged a higher price or fee? Please describe below:

Who do you believe discriminated against you? Was it a manager, owner, food server, company or organization?

Name:
Title/Position:
Address:
City:   State:   Zip code:

Where did the alleged act of discrimination occur? Provide the address and indicate the type of facility.

Type:
Address:
City:   State:   Zip code:

When did the last act of discrimination occur?
Enter the date (mm/dd/yyyy)

Is the alleged discrimination on going? Yes No

*required fields

Use the submit button below to e-mail your completed form.

If you prefer, you may call, mail or fax the completed questionnaire to the Equal Opportunity Department at:

City of Phoenix Equal Opportunity Department
Compliance & Enforcement Division
251 W. Washington St. 7th Floor
Phoenix, AZ 85003
602-262-7486/voice     602-534-1557/TTY     602-495-0517/fax

Every attempt will be made to contact you within 48 hours of receipt of your complaint by the Equal Opportunity Department.

Before you submit this form, we would like you to be aware of the city's policy on the use of its e-mail systems. The policy states that the e-mail message you are about to send: (1) is subject to public disclosure under the Public Records Law, (2) is not private or confidential and (3) is retained for one month.