ࡱ> psmnoi Bbjbj^^ <j<jp,9WWieieieieieDeee-f!gdegn5n5n5n}o<v<x ~\iez}o}ozzieie5n5nHzFie5nie5nz.5n W[z@u0zn,ie)LzzzzzzzcDzzzzzzzzzzzzzzzzWY /d:  COMPLAINT FORM The 鱨վ investigates and conciliates complaints about discrimination and breaches of human rights. We will need to contact you about your complaint, so please provide your name and contact details, including one contact number if possible. If you do not provide this information we may not be able to deal with your complaint. Part A 鱨վ you, the complainant Title:  FORMTEXT       First name:  FORMTEXT       Last name:  FORMTEXT       Address:  FORMTEXT       Suburb:  FORMTEXT       State/Territory:  FORMTEXT       Postcode:  FORMTEXT       Mobile :  FORMTEXT       Phone (AH):  FORMTEXT       Phone (BH):  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. Title:  FORMTEXT       First name:  FORMTEXT       Last name:  FORMTEXT       Email:  FORMTEXT       What is their relationship to you?  FORMTEXT       Please advise if they need assistance to participate in the complaint process and the kind of assistance they need:  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. 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       Please advise if they need assistance to participate in the complaint process and the kind of assistance they need:  FORMTEXT       Part B  Who is the complaint about? Respondent 1 Name of person or organisation:  FORMTEXT       ABN/ACN of organisation (if relevant):  FORMTEXT       Address:  FORMTEXT       Suburb:  FORMTEXT       State/Territory:  FORMTEXT       Postcode:  FORMTEXT       Email:  FORMTEXT       Phone (BH):  FORMTEXT       Mobile:  FORMTEXT       What is your relationship to this respondent?  FORMTEXT       Respondent 2 Name of person or organisation:  FORMTEXT       ABN/ACN of organisation (if relevant):  FORMTEXT       Address:  FORMTEXT       Suburb:  FORMTEXT       State/Territory:  FORMTEXT       Postcode:  FORMTEXT       Email:  FORMTEXT       Phone (BH):  FORMTEXT       Mobile:  FORMTEXT       What is your relationship to this respondent?  FORMTEXT       Note: If you are complaining about more than two people or organisations, please provide information about each additional person or organisation.  FORMTEXT       Part C  What are you complaining about? For information about the types of complaints the Commission can consider, please go to our HYPERLINK "https://humanrights.gov.au/our-work/complaint-information-service/information-people-making-complaints"website. I am complaining because I believe: (Please select at least one reason below)  FORMTEXT    FORMCHECKBOX  I have been discriminated against because of my  FORMCHECKBOX  Age What is your age?  FORMTEXT        FORMCHECKBOX  Disability What is your disability?  FORMTEXT        FORMCHECKBOX  Association with a person with a disability What is the person s disability?  FORMTEXT        FORMCHECKBOX  Status as a person with a disability who uses an assistance animal or disability aid or has a carer  FORMCHECKBOX  Sex What is your sex?  FORMTEXT        FORMCHECKBOX  Pregnancy  FORMCHECKBOX  Breastfeeding  FORMCHECKBOX  Marital or relationship status What is your marital or relationship status?  FORMTEXT        FORMCHECKBOX  Family responsibilities  FORMCHECKBOX  Sexual orientation What is your sexual orientation?  FORMTEXT        FORMCHECKBOX  Gender identity What gender do you identify as?  FORMTEXT        FORMCHECKBOX  Intersex status  FORMCHECKBOX  Race (this includes colour, national origin, descent or ethnic origin) What is your race/national or ethnic origin/descent?  FORMTEXT        FORMCHECKBOX  I have been sexually harassed  FORMCHECKBOX  I have experienced sex based harassment  FORMCHECKBOX  I have been subjected to a hostile workplace on the ground of sex  FORMCHECKBOX  I have experienced racial hatred What is your race/national or ethnic origin/descent?  FORMTEXT        FORMCHECKBOX  I have been discriminated against in my employment because of my  FORMCHECKBOX  Trade union activity  FORMCHECKBOX  Criminal record What is your criminal record?  FORMTEXT        FORMCHECKBOX  Religion What is your religion?  FORMTEXT        FORMCHECKBOX  Political opinion What is your political opinion?  FORMTEXT        FORMCHECKBOX  My human rights have been breached by a Commonwealth government body.  FORMCHECKBOX  I have been victimised because I made, or tried to make, a complaint about discrimination When did the alleged event(s) happen?  FORMTEXT       Note: The President of the Commission can decide not to investigate into a complaint alleging unlawful discrimination where the complaint is lodged more than twenty four (24) months after the alleged events(s) happened. If the event(s) being complained about happened more than twenty four (24) months ago, please explain the reasons for the delay in making a complaint to the Commission. For complaints alleging human rights breaches and discrimination in employment under the ILO Convention, the relevant time frame is twelve (12) months. Reason(s) for delay:  FORMTEXT       What happened? Describe the event(s) 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. 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FORMTEXT       Supporting documents If you would like the Commission to consider any further relevant information, please list out the documents you have that you believe support the claims in your complaint. If the Commission wants you to provide this information, we will ask you for it.  FORMTEXT       How do you think this complaint could be resolved? For example, a complaint may be resolved with an agreement that a respondent will change its procedures, introduce training or policies on anti-discrimination, take other action to prevent possible discrimination and/or by payment of compensation.  FORMTEXT       Have you made a complaint to another organisation? For example, a state anti-discrimination or equal opportunity agency, a worker s compensation agency, an ombudsman or the Fair Work Commission. If yes, you must provide the name of the agency, the date the complaint was made, the status of the complaint, or outcome of the complaint. Please also attach copies of relevant documents, including a copy of your complaint and any letters you have received from the agency.  FORMTEXT       Were you referred to the Commission by another organisation? If so, what organisation?  FORMTEXT       Part D  Lodging the complaint ICS Privacy Collection Notice The Australian Human Rights Commission (Commission) collects and handles personal information in accordance with the/ Privacy Act 1988/ (Cth), the/ Archives Act 1983/ (Cth) and our/ HYPERLINK "https://humanrights.gov.au/our-work/commission-general/privacy" \t "_blank"Privacy Policy. By completing this complaint form and providing us with your personal information and sensitive information as part of the Commission s complaints process under the Australian Human Rights Commission Act 1986 (Cth) (AHRC Act), you consent to us collecting your personal information and sensitive information and using it for the purposes set out below. We collect personal information about complainants, respondents and third parties in the course of receiving and handling complaints made under the AHRC Act. Personal information about an individual may be collected by the Commission from a complainant, respondent or third party and may be received in various ways, including through our online complaint form, responses to complaints, by email, by letter or by phone. We will use the personal information provided to us for the purposes of administering our functions under the AHRC Act, including to assess, investigate and conciliate a complaint, analyse trends, prepare statistical data and report on complaints received by the Commission and maintain the Commission s conciliation register. If we accept a complaint, we will usually provide a copy (excluding the complainant s contact details) to the person or organisation being complained about. Where necessary, we may also provide a copy to others who are related to, or are named in, the complaint. We may also share other information provided by a complainant, respondent or third party with other parties to the complaint and any third party who may be relevant to the complaint for the purposes of handling the complaint. To properly handle a complaint, it may be necessary for us to disclose personal information we collect as part of our complaints function to an overseas recipient. For example, where: a party to a complaint is based overseas an Australian-based respondent is the related body corporate to an overseas company you have complained to an overseas entity and the Commission about the same or a related matter. If we receive the personal information of third parties who are not a party to a complaint, we will also collect this information. We may not inform those third parties that their information has been collected and will only use their personal information to the extent necessary to perform our functions under the AHRC Act. Information provided in making, responding to, or providing a contribution related to a complaint, including information about parties and allegations made in a complaint, may be used for statistical or research purposes, as case studies, as examples, and to improve our service delivery. This includes any survey responses related to the complaints process. Any published information, case study or example will not include names or information that may identify an individual. Our/ HYPERLINK "https://humanrights.gov.au/our-work/commission-general/privacy" \t "_blank"Privacy Policy/ sets out how you can make a complaint about how we have handled your information and how we will deal with your complaint. 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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`DCTitleComplainant's titleD CFirstnameComplainant's first nameD CLastnameComplainant's last nameDCAddressComplainant's addressDCSuburbComplainant's suburbDCStateorterritory Complainant's state or territoryD CPostcodeComplainant's postcodeDCMobileComplainant's mobileDCPhoneafterhours!Complainant's phone (after hours)DCPhonebusinesshours$Complainant's phone (business hours)fDAssistancerequiredlIf you require assistance to participate in the complaint process, please outline the assistance you requireDOBOTitleOn behalf of person's titleD OBOFirstname On behalf of person's first nameD OBOLastnameOn behalf of person's last nameDCEmailComplainant's email addressDOBORelationship*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. DRepTitleRepresentative'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 numberD RepAssistanceIf the representative requires assistance to participate in the complaint process, please outline the assistance they require. DR1NameRespondent 1's nameDR1ABN0Respondent 1's ABN of organisation (if relevant)D 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 numberfD~What is your relationship to this respondent? For example, are they your employer, landlord or provider of goods and services?DR2NameRespondent 2's nameDR2ABN0Respondent 2's ABN of organisation (if relevant)D 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 numberfD~What is your relationship to this respondent? For example, are they your employer, landlord or provider of goods and services?DRespondentextraIf you are complaining about more than two people or organisations, please provide information about each additional person or organisatonWDyK yK https://humanrights.gov.au/our-work/complaint-information-service/information-people-making-complaintsyX;H,]ą'cBDNotecomplaintgroundsXHeading: I am complaining because I believe: (Please select at least one reason below) (DSexdiscriminationThis includes sex, pregnancy, marital or relationship status, family responsibilities, breastfeeding, gender identity, sexual orientation and intersex status. /I have been discriminated against because of mytDeCheck1DDatefoallegedevents"When did the alleged events happentDeCheck1DDatefoallegedevents"When did the alleged events happentDeCheck1DDatefoallegedevents"When did the alleged events happentDeCheck1tDeCheck1DDatefoallegedevents"When did the alleged events happentDeCheck1tDeCheck1tDeCheck1D"When did the alleged events happentDeCheck1tDeCheck1D"When did the alleged events happentDeCheck1D"When did the alleged events happentDeCheck1tDeCheck1D"When did the alleged events happenDeSexualharasssmentI have been sexually harassed. DeSexualharasssmentI have been sexually harassed. DSexualharasssmentI have been sexually harassed. De Racialhatred"I have experienced racial hatred. D"When did the alleged events happenDI 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. D"When did the alleged events happenxDReligion5This ground only applies in employment or occupation.KI have been discriminated against in my employment because of my religion. D"When did the alleged events happenDPoliticalopinion5This ground only applies in employment or occupation.TI have been discriminated against in my employment because of my political opinion. D"When did the alleged events happenDHumanrightsbreach;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 victimisationDDatefoallegedevents"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?DPlease 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 documentsD2How do you think this complaint could be resolved?D.Details about your complaint to another agency,D ReferredbyWWere you referred to the Commission by another organisation? If so, what organisation? 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