National Association for the Advancement of Color People
Ventura County Chapter
P.O. Box 5792
Oxnard, CA 93031
(805) 201 0475
COMPLAINT FORM
NAACP Human Rights Complaint Form
Date of report: ___________________
(Please check the type of complaint that you are making)
□ Retaliation Discrimination Harassment Housing □ Civil Rights violation/Hate crimes
Please select the agency, organization and/or person of which you are filing the complaint against:
□ Place of Business □ Employer
□ School District
□ Government Agency
□ Law Enforcement
□Other ___________________
Date(s) incident occurred: ________________
**Please provide the following information about yourself**
Name: _________________________________________________________________
(First, Middle, Last Name)
Address: _______________________________________________________________
Street City, State Zip ____________________________________________________
Home Telephone #: (
) ________________ Work #: (
) ___________________
Email address____________________________________________________________
Work Location: __________________________________________________________
Do you currently have an attorney working in your behalf? (Circle One) Yes
No
Not sure
**If yes, provide information below**
Attorney’s Name: ________________________________________________________
Attorney’s Address: ______________________________________________________
City, State & Zip: ________________________________________________________
NAACP Human Rights Complaint Form
Ventura County Unit #1053
Page 1
National Association for the Advancement of Color People
Ventura County Chapter
P.O. Box 5792
Oxnard, CA 93031
(805) 201 0475
COMPLAINT FORM
Attorney’s Telephone #: ____________________ Fax #: ________________________
Has a lawsuit been filed? (Circle One)
Yes
No
not sure
If yes, when filed? _________________In what city? ______________ In what court? ____________
Date Filed _____________________ (mm/dd/yyyy)
Have you filed an EEOC complaint? (Circle One) Yes
No
Not sure
If yes, when filed? _________________ Case # ______________ Right to sue letter?
sure
Yes
No
Not
No
Not
Date filed _____________________ (mm/dd/yyyy)
Have you filed a Fair Employment & Housing complaint? (Circle One) Yes
No
Not sure
If yes, when filed? _________________ Case # ______________ Right to sue letter?
sure
Yes
Date Filed ____________________ (mm/dd/yyyy)
Please include copies of filed complaints and right to sue letters upon submitting this completed form.
NAACP Human Rights Complaint Form
Please complete the following about your employer and/or complainant:
Employer (or former employer) Name:
_____________________________________________________________________________________
Address:
______________________________________________________________________________
Street City, State Zip ____________________________________________________________________
Telephone: (________) ________________ Fax #: (________) ________________
Supervisor’s Name: ______________________________ Business Agent/Steward ________________
District: ______________________________________
NAACP Human Rights Complaint Form
Ventura County Unit #1053
Field Base Office ________________
Page 2
National Association for the Advancement of Color People
Ventura County Chapter
P.O. Box 5792
Oxnard, CA 93031
(805) 201 0475
COMPLAINT FORM
Time: ______Please check the box that best describes when the incident occurred.
Before
During
After Shift
Local Union’s Name: _____________________________________________________
Local Union’s Address: ___________________________________________________
City, State & Zip: ________________________________________________________
Local Union’s Telephone #: _______________________ Fax #: __________________
Has a grievance or complaint been filed? (Circle One) Yes
No
If yes, what is the status of that grievance or complaint?
Closed
Not sure
In progress
Not sure
Comments:____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Description of incident: (please copy form if more pages are needed)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
NAACP Human Rights Complaint Form
Ventura County Unit #1053
Page 3
National Association for the Advancement of Color People
Ventura County Chapter
P.O. Box 5792
Oxnard, CA 93031
(805) 201 0475
COMPLAINT FORM
I affirm that the statements I have made above are accurate and true to the best of my knowledge and
belief. I hereby voluntarily request the assistance of the NAACP in seeking remedy of the situation
described above
I, ________________________ do hereby authorize the NAACP Legal Redress Committee, and the
officers of the NAACP to have access to information and documents which are relevant to my claim of
discrimination as described above and to investigate my complaint and to take any steps necessary to
resolve it, and I understand that the NAACP is not a legal entity and that the organization has certain
limitations as to the scope of their influence and ability.
.
_________________________
___________
Signature
Date
Submit completed forms to:
NAACP Ventura County
Attn: Legal Redress
PO Box 5792
Oxnard, CA 93031
________________________
Witness
____________
Date
Or email:
[email protected]
For questions call (805) 201-0475.
(Internal Use Only) _____________________________________________________________________
TO BE COMPLETED BY NAACP LEGAL REDRESS
NAACP Human Rights Complaint Form
Date of Branch receipt: _________________________ Date of Committee receipt: _________________
[ ] Committee Review _______________ Date: ______________________________
Committee Action:
NAACP Human Rights Complaint Form
Ventura County Unit #1053
Page 4
National Association for the Advancement of Color People
Ventura County Chapter
P.O. Box 5792
Oxnard, CA 93031
(805) 201 0475
COMPLAINT FORM
[ ] Assigned/Requested Case Number _________________________________ Date _______________
Assigned to: _______________________________________
[ ] Logged onto log sheet ____________________________________________Date _______________
[ ] Telephone Call _________________________________________________ Date _______________
[ ] Mailed forms __________________________________________________ Date _______________
[ ] Referred to ____________________________________________________ Date _______________
[ ] Other ________________________________________________________ Date _______________
Committee/Branch notes: (initial and date all notations made)
NAACP Human Rights Complaint Form
Ventura County Unit #1053
Page 5