ࡱ> RUOPQg DgbjbjVV |r<r<\?UU(c(c(c(c(cDlclclccdLlcndkkkkl` Vv by$r$`%(czllzz%(c(ckkHzL(ck(ckz'TǬki6{{:Ա0{tǬǬ\(c#zzzzzzz%%zzzzzzzzzzzzzzzzU a:  COMPLAINT FORM  FORMTEXT * The 鱨վ investigates and conciliates complaints about discrimination and breaches of human rights.  FORMTEXT * If you have any queries or need help to complete this form, please contact our Complaint Infoline on 1300 656 419 or 02 9284 9600.  FORMTEXT * Please note that we cannot accept anonymous complaints. Please provide your name and contact details. If your contact details change after making the complaint, please contact us on 1300 656 419.  FORMTEXT * Part A  About you, the complainant  FORMTEXT * Title:  FORMTEXT       First name:  FORMTEXT       Last name:  FORMTEXT       Address:  FORMTEXT       Suburb:  FORMTEXT       State/Territory:  FORMTEXT       Postcode:  FORMTEXT       Email:  FORMTEXT       Phone (AH):  FORMTEXT       Phone (BH):  FORMTEXT       Mobile :  FORMTEXT       Fax:  FORMTEXT       TTY:  FORMTEXT       If you require assistance to participate in the complaint process, please outline the assistance you require:  FORMTEXT       If you are complaining on behalf of someone else, please provide the following details about this person.  FORMTEXT * Title:  FORMTEXT       First name:  FORMTEXT       Last name:  FORMTEXT       Address:  FORMTEXT       Suburb:  FORMTEXT       State/Territory:  FORMTEXT       Postcode:  FORMTEXT       What is your relationship to this person?  FORMTEXT       If they require assistance to participate in the complaint process, please outline the assistance they require:  FORMTEXT       If someone is assisting you with the complaint, for example, a legal representative, advocate or union representative, please provide the following details about this person.  FORMTEXT * Title:  FORMTEXT       First name:  FORMTEXT       Last name:  FORMTEXT       Position:  FORMTEXT       Organisation:  FORMTEXT       Address:  FORMTEXT       Suburb:  FORMTEXT       State/Territory:  FORMTEXT       Postcode:  FORMTEXT       Email:  FORMTEXT       Phone (BH):  FORMTEXT       Mobile:  FORMTEXT       Fax:  FORMTEXT       TTY:  FORMTEXT       If they require assistance to participate in the complaint process, please outline the assistance they require:  FORMTEXT       Part B  Who is the complaint about?  FORMTEXT * Respondent 1  FORMTEXT * Name of person or organisation:  FORMTEXT       Address:  FORMTEXT       Suburb:  FORMTEXT       State/Territory:  FORMTEXT       Postcode:  FORMTEXT       Email:  FORMTEXT       Phone (BH):  FORMTEXT       Mobile:  FORMTEXT       Fax:  FORMTEXT       TTY:  FORMTEXT       What is your relationship to this respondent?  FORMTEXT       Respondent 2  FORMTEXT * Name of person or organisation:  FORMTEXT       Address:  FORMTEXT       Suburb:  FORMTEXT       State/Territory:  FORMTEXT       Postcode:  FORMTEXT       Email:  FORMTEXT       Phone (BH):  FORMTEXT       Mobile:  FORMTEXT       Fax:  FORMTEXT       TTY:  FORMTEXT       What is your relationship to this respondent?  FORMTEXT       Note: If you are complaining about more than two people or organisations, please provide this additional information.  FORMTEXT       Part C  What are you complaining about?  FORMTEXT * I am complaining because I believe: (Please select at least one reason below)  FORMTEXT *  FORMCHECKBOX  I have been discriminated against because of my sex. This includes sex, pregnancy, marital or relationship status, family responsibilities, breastfeeding, sexual orientation, gender identity and intersex status.  FORMCHECKBOX  I have been sexually harassed  FORMCHECKBOX  I have been discriminated against because of my race. This includes race, colour, national origin, descent, ethnicity and immigrant status.  FORMCHECKBOX  I have experienced racial hatred.  FORMCHECKBOX  I have been discriminated against because of my disability. This includes disability, association with a person with a disability, being a carer or an assistant of a person with a disability, use of an assistance animal, harassment because of a disability and contravention of a disability standard.  FORMCHECKBOX  I have been discriminated against because of my age.  FORMCHECKBOX  I have been discriminated against in my employment because of one, or more,  !"8 9 C D E F G   0 2 4 6 8 : < ѹѵwshw_wh> @mHnHuj8h> @Uh> @jh> @UjhjUhjmHnHuj.hjUhjjhjUhK hKhKh*h6mHnHujxh6Uh6jh6Uh%d h(h| h5h|hg$ jh#uh*6UmHnHu$!"H I : < " b & d " dhgdg$gdg$dgdg$-DM gd*6gdKdgdg$gd|<     4 6 : < P R T ^ ` p r v x ȐsȐjhgUmHnHujZhgUhgjhgUjh> @Ujh> @UmHnHujh> @Uh> @jh> @UhYrhMYDhg$h(hLf mHnHuj@hLf UhLf jhLf Uh%dhr,,    " $ 6 8 < > R T V ` b n p v x  ҸҭҢҗjhhgUjhgUjhgUjHhgUhuz jhgUhghMYDhYrjhgUmHnHujhgUjhgU7    0 2 6 8 L N P Z \ d f l n Ҽұکڄ|w h $5hsh55hshYr5jh ;UmHnHujh ;Uh ;jh ;UjLhgUjhgUj hgUhghMYDhYrjhgUmHnHujhgUj4hgU-" ^ HH   Jgdg$gdg$ dhgdg$ "68:DFZ\`bvxzɽɽɽɂ~sjhhi]Uhi]jhi]UjhgUjhgUjhgUmHnHuj8hgUhgjhgUhMYDh5hshsh55hLf 5mHnHujThLf 5U hLf 5jhLf 5U* "68:DFXZ^`tvx޽汭⌄ujLh ;Uh ;jh ;Uh'WhYrjh0UmHnHujph0Uh0jh0Uh8HDjhi]Ujhi]Uj hi]Uhi]hMYDh5jhi]Ujhi]UmHnHu. jln"$8ƹˮ⢞}yn}`}}yjh}UmHnHujh}Uh}jh}UjhA6$UmHnHujhA6$UhA6$jhA6$UhMYDhLf 5mHnHujhLf 5U hLf 5jhLf 5U hM.5hsh55h5h'Wjh ;Ujh ;UmHnHu$8:<FHZ\`bvxz246@Bbdfh|~ҼұҦқҐjh}Ujh}Uj*h}Uj|h}Ujh}Ujh}Uh}hMYDh5jh}UmHnHujh}Uj<h}U8 DHdf FBgdg$gdg$dgdg$gd9 g dhgdg$ "68:DFTVZ\prt~޹汭މąh'Wj<h}UjhlUmHnHujhlUhljhlUjh}Uhjh}UjVh}Uh}hMYDh5jh}Ujh}UmHnHu3BDFZ\^`bdf~ 468BDR֣֛~֣֛s~j h?zUjh?zUmHnHujh?zUh?zjh?zUhj:hLf Uhg$h5hLf mHnHujjhLf UhM.hAh'WjhLf UmHnHujhLf UhLf jhLf U-RTXZnpr|~024>@VX\^rtvǼˮǣˮǘˮǍˮǂj hgUj hgUjl hgUj hgUjhgUmHnHuj hgUhgjhgUjh?zUmHnHuj@ h?zUh?zjh?zUh'Wh3&(*(*,.B搈yphLf mHnHujThLf UhLf jhLf UhM.hi]jhIEUmHnHujhIEUhIEjhIEUh0 h0h0jHhgUjhgUhghh'WjhgUjhgUmHnHu,*TR>t!!!!!!"""dgdg$gdg$gdg$ dhgdg$BDFPRbdhj~$&*,@BDNP\^dfz|~ҼұҦқҐj<hgUjhgUjhgUjhgUjlhgUjhgUhghh'WjhgUmHnHujhgUj(hgU8,.0:<DFLNbdfprt ޽液}rjrhM.UhM.jhM.Uhg$jhvUmHnHuj hvUhvjhvUh0 h0h0jfhgUjhgUjhgUhghh'WjhgUjhgUmHnHu, ! ! !`!b!d!x!z!|!~!!!!""""""" "!"""#"1"2"3"4"5"k""" # # # ###ղ宦宏zrncj2 h ;Uh ;jh ;U h6hF h6h8C h6h'Wh6h'W5jhvUhvjhvUhFjhLf Uhg$hLf mHnHujhLf UhLf jhLf Uhh'WjhM.UmHnHujhM.U&""k" # #<#=####$$c$S%T%%%8PPPPPQQNQ^`gdg$0^`0gdg$ ^gdg$gdg$###;#<#=#>#L#M#N#P##########$$$$"$#$$$&$a$c$S%T%U%c%d%e%g%%%%%%%%%%%Pźۨ۝瑍zxUh6h/5j&hwUhwjhwUh'Wj&hIEUj>#hIEU hFhFjz"h ;Uh ; h6hFj hIEUhIEjhIEUhg$h6hF5hFjh ;U/ of the following reasons:  FORMCHECKBOX  trade union activity  FORMCHECKBOX  criminal record  FORMCHECKBOX  religion  FORMCHECKBOX  political opinion  FORMCHECKBOX  My human rights have been breached by a Commonwealth government body.  FORMCHECKBOX  I have been treated unfairly because of another reason, including victimisation. There are limits on the types of complaints the Commission can consider. The Commission can only consider complaints about unfair treatment related to the reasons listed above. If another reason is selected, please state the reason:  FORMTEXT       When did the alleged event(s) happen  FORMTEXT       Note: The President of the Commission can decide not to investigate a complaint where the complaint is lodged more than twelve months after the alleged event(s) happened. If the event(s) being complained about happened more than twelve months ago, please explain the reason(s) for the delay in making a complaint to the Commission. Reasons for delay:  FORMTEXT       What happened? Describe the events that you want to complain about. We need to know what you say happened, where it happened and who was involved. Please give us all the dates and other details that you can remember. If you are complaining about employment, please tell us when you commenced employment, your job title and whether you are still employed.  FORMTEXT       Signature:  FORMTEXT       Date:  FORMTEXT       Supporting documents Please attach copies of any documents that may help us consider your complaint, for example, letters, pay slips, doctor s certificates or references. If you cannot do this, please tell us about the documents or other information and how this information can be obtained.  FORMTEXT       How do you think this complaint could be resolved?  FORMTEXT       Have you made a complaint to another organisation? For example, a state anti discrimination or equal opportunity agency, a workers compensation agency, an ombudsman or an industrial relations commission. If you have complained to another agency, you must provide details of the complaint and its outcome. You should also attach copies of any letters you have received from the agency.  FORMTEXT       Were you referred to the Commission by another organisation?  FORMTEXT       Part D  Lodging the complaint  FORMTEXT *  FORMTEXT * Before sending the complaint to the Commission, please: Review the form to make sure the information you have provided is correct; Attach copies of any relevant documents; and Sign and date the form in the space provided on the form. 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E (]*c!DN=h;c-Oi3ι}p!^E˭^+(jh,oܱ K)o%TMc~GǎF h߁Y2"5U$W+U@mLM7P8O.ھNTw!Ǫ&ڢF hnK ҥ0lسHhU/OLe$:by2iSFߊF hfp݆\2IENDB`D Formtitle*Heading: AHRC Complaint FormD Intropart1*The Australian Human Rights Commission investigates and conciliates complaints about discrimination and breaches of human rights. D Intropart2*If you have any queries or need help to complete this form, please contact our Complaint Infoline on 1300 656 419 or 02 9284 9600. D Intropart3*_ If your contact details change after making the complaint, please contact us on 1300 656 419. ePlease note that we cannot accept anonymous complaints. Please provide your name and contact details.DPartA*,Heading: Part A - About you, the complainantDCTitleComplainant's titleD CFirstnameComplainant's first nameD CLastnameComplainant's last nameDCAddressComplainant's addressDCSuburbComplainant's suburbDCStateorterritory Complainant's state or territoryD CPostcodeComplainant's postcodeDCEmailComplainant's email addressDCPhoneafterhours!Complainant's phone (after hours)DCPhonebusinesshours$Complainant's phone (business hours)DCMobileComplainant's mobileDFaxComplainant's fax numberDCTTYComplainant's TTY numberfDAssistancerequiredlIf you require assistance to participate in the complaint process, please outline the assistance you requireD SectionOBO*jIf you are complaining on behalf of someone else, please provide the following details about this person. HHeading: Details of the person you are complaining on behalf of, if any.DOBOTitleOn behalf of person's titleD OBOFirstname On behalf of person's first nameD OBOLastnameOn behalf of person's last nameD OBOAddressOn behalf of person's addressD OBOSuburbOn behalf of person's suburbDOBOStateorterritory(On behalf of person's state or territoryD OBOPostcodeOn behalf of person's postcodeDOBORelationship*What is your relationship to this person? tD OBOassistancexIf this person requires assistance to participate in the complaint process, please outline the assistance they require. D SectionRep*If someone is assisting you with the complaint, for example, a legal representative, advocate or union representative, please provide the following details about this person.!Heading: Representative's detailsDRepTitleRepresentative's titleD RepFirstnameRepresentative's first nameD RepLastnameRepresentative's last nameD RepPositionRepresentative's positionDRepOrganisation OrganisationRepresentative's organisationD RepAddressRepresentative's addressD RepSuburbRepresentative's suburbDStateorterritory#Representative's state or territoryD RepPostcodeRepresentative's postcodeDRepresentative's email addressDPhonebusinesshours'Representative's phone (business hours)D RepMobileRepresentative's mobile numberDRepFaxRepresentative's fax numberDRepTTYRepresentative's TTY numberD RepAssistanceIf the representative requires assistance to participate in the complaint process, please outline the assistance they require. DPartB*-Heading: Part B - Who is the complaint about?D Respondent1* Heading: Details of Respondent 1DR1NameRespondent 1's nameD R1AddressRespondent 1's addressDR1SuburbSuburbRespondent 1's suburbDR1Stateorterritory!Respondent 1's state or territoryD R1PostcodeRespondent 1's postcodeDRepEmailRespondent 1's email addressDR1Phonebushours%Respondent 1's phone (business hours)DR1MobileRespondent 1's mobile numberDR1FaxRespondent 1's fax numberDR1TTYRespondent 1's TTY numberfD~What is your relationship to this respondent? For example, are they your employer, landlord or provider of goods and services?D Respondent2*)Heading: Details of Respondent 2 (if any)DR2NameRespondent 2's nameD R2AddressRespondent 2's addressDR2SuburbRespondent 2's suburbDR2StateorTerritory!Respondent 2's state or territoryD R2PostcodeRespondent 2's postcodeDR2EmailRespondent 2's email addressDR2Phonebushours%Respondent 2's phone (business hours)DR2MobileRespondent 2's mobile numberDR2FaxRespondent 2's fax numberDR2TTYRespondent 2's TTY numberfD~What is your relationship to this respondent? For example, are they your employer, landlord or provider of goods and services?rDRespondentextrauIf you are complaining about more than two people or organisations, please provide this additional information here. DPartC*1Heading: Part C  What are you complaining about?DDNotecomplaintgrounds*XHeading: I am complaining because I believe: (Please select at least one reason below) 2DSexdiscriminationThis includes sex, pregnancy, marital or relationship status, family responsibilities, breastfeeding, gender identity, sexual orientation and intersex status. 5I have been discriminated against because of my sex. DeSexualharasssmentI have been sexually harassed. DVThis includes race, colour, national origin, descent, ethnicity and immigrant status. 6I have been discriminated against because of my race. De Racialhatred"I have experienced racial hatred. DThis includes disability, association with a person with a disability, being a carer or an assistant of a person with a disability, use of an assistance animal, harassment because of a disability and contravention of a disability standard.>I have been discriminated against because of my disability. De5I have been discriminated against because of my age. DI have been discriminated against in my employment because of one or more of the following grounds: trade union activity, criminal record, religion or political opinion (individual checkboxes to follow). iI have been discriminated against in my employment because of one or more of the following four grounds. DTradeunionactivity5This ground only applies in employment or occupation.WI have been discriminated against in my employment because of my trade union activity. DCriminalrecord5This ground only applies in employment or occupation.RI have been discriminated against in my employment because of my criminal record. xDReligion5This ground only applies in employment or occupation.KI have been discriminated against in my employment because of my religion. DPoliticalopinion5This ground only applies in employment or occupation.TI have been discriminated against in my employment because of my political opinion. DHumanrightsbreach;This ground only applies to the Commonwealth of Australia. FMy human rights have been breached by a Commonwealth government body. hDThere are limits on the types of complaints the Commission can consider. The Commission can only consider complaints about unfair treatment related to the reasons listed above. OI have been treated unfairly because of another reason, including victimisationDOtherreasonexp8If another reason is selected, please state the reason. DDatefoallegedevents"When did the alleged events happenDThe President of the Commission can decide not to investigate a complaint where the complaint is lodged more than twelve months after the alleged events happened. Please explain the reasons for the delay, if any. 7Reasons for the delay in lodging the complaint, if any.DDescribe the events that you want to complain about. We need to know what you say happened, where it happened and who was involved. Please give us all the dates and other details that you can remember. What happened?D Signature SignatureDDateofsubmissionDate of submissionDPlease attach copies of any documents that may help us consider your complaint, for example, letters, pay slips, doctor s certificates or references. If you cannot do this, please tell us about the documents or information and how they can be obtained. Supporting documentsD Resolution2How do you think this complaint could be resolved?DFor example, a state anti discrimination or equal opportunity agency, a workers compensation agency, an ombudsman or an industrial relations commission. If you have complained to another agency, you must provide details of the complaint and its outcome.2Have you made a complaint to another organisation?D=Were you referred to the Commission by another organisation? DPartD*Before sending the complaint to the Commission, please review the form to make sure the information you have provided is correct, attach copies of any relevant documents and sign and date the form in the space provided on the form, if possible. 'Heading: Part D - Lodging the complaintXD Wheretolodge*You can return the form either by post, to Australian Human Rights Commission, GPO Box 5218 Sydney NSW 2001, by fax 02 9284 9611 or by email to newcomplaints@humanrights.gov.au. 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