NMDWS

HUMAN RIGHTS BUREAU DISCRIMINATION INQUIRY FORM

Personal Information
Indicates the fields required in the form and cannot be left blank.


Organization’s Information (involved in the alleged illegal action(s))
Address where alleged illegal action(s) occurred (if not same as mailing address):

Same as the above organization address?


Alleged Violation(s)
Type of Violation Alleged. Check all that apply.





Are you raising an issue about being paid less than the opposite sex for equal work?
Are you raising an issue about being asked about your arrests or convictions on an employment application?
Are you raising an issue about your employer not letting you use paid sick leave to care for a family member?
Are you raising an issue about being discriminated against for engaging in legal activity related to the use of medical cannabis?
You Are Alleging Discrimination, What Is the Reason(Basis) For Your Claim? Check all that apply.

For example, if you feel that you were treated differently than someone else because of your race, you should check the box next to “Race.” If you feel that you were treated differently for more than one reason, check all that apply.


















Are you alleging you were retaliated against?

Employment Information
(if applicable):

Duration of Alleged Violation

Urgent Medical Condition

Individual(s) Whom You Allege Acted Illegally
Complete this section only if you would like to name an individual in your complaint.

Do you wish to name an individual in your complaint?

Filings
Did you file a charge in this matter with U.S. Equal Employment Opportunity Commission (EEOC)?
Do you currently have legal representation in this matter?
Allegations Details
What happened to you that you believe is against the law?
Please Explain: