complaint form

To be filled out by complainant (or by person assisting him/her). If you need help please contact us here.

Part A – About you (The Complainant)
This box seeks data about the complainant (if the complainant is an individual) that will be used for internal statistical purposes only. Please tick/ highlight as appropriate
This box is to filled out if the complainant is being assisted/ represented by someone else, for example an Attorney-at-Law, a Corporate Officer or Board Member, a Trade Union representative, a Parent, Spouse or Child.
Please identify the person/ organisation/ body about whom you are complaining. (The Respondent)

Contact Numbers

If you are complaining about two persons / organisations / bodies, please list the second below.

Contact Numbers

Please tick/ highlight as appropriate which of the following you wish to complain about.

[The Explanatory Notes in the square brackets are meant for general guidance only. Please contact us by telephone or in writing by letter or e-mail if you want any assistance or clarification.]

Where you have been treated differently and/or unfavourably because of one or more of the following reasons (i.e. your status):

(d)

Please indicate when did this happen? (day/month/year)

Please describe what happened?

Please provide details of the events that you want to complaint about, including things like:

(a) What Happened;
(b) Where it Happened;
(c) Who said or did what to you;
(d) If you are complaining about discrimination, please provide the names of other persons who you feel were treated better/ more favourably than you were;
(e) If you are complaining about discrimination in employment, please tell us when you began employment, whether you have been offered or have signed a contract, your job title and whether you are still employed.
Any action(s) that you have already taken to address your complaint

Have you tried to resolve your complaint directly with the Respondent(s)?
(For example: through a report or through an internal grievance/ complaint process)

If so, you must provide details of
  • (a) What action you took;
  • (b) If a report or complaint, the way it was made (orally or in writing) and the person to whom it was made;
  • (c) The date on which you did this;
  • (d) Any outcome (whether you were contacted, invited to a meeting and such like); and
  • (e) Documents, correspondence, claims or responses (if any) that you sent and/or received from the Respondent(s) (please attach copies of same if possible).

Have you made a complaint about this to another Agency or Entity?

(For example: an Attorney-at-Law, a Trade Union, the Ombudsman, any Public Body/Authority [e.g. Consumer Affairs], any Regulatory Agency, any Civil Advocacy Group or any Non-governmental Organisation)BR>
  • (a) What action you took;
  • (b) If a report or complaint, the way it was made (orally or in writing) and the person to whom it was made;
  • (c) The date on which you did this;
  • (d) Any outcome (whether you were contacted, invited to a meeting and such like); and
  • (e) Documents, correspondence, claims or responses (if any) that you sent and/or received from the Respondent(s) (please attach copies of same if possible).

Supporting evidence

Please attach copies of any documents that may help us investigate 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 evidence and how this evidence can be obtained.

Please check this box if attaching separate documents.
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How has this affected you?

Please tell us how what you are complaining about has affected you?

What outcome are you seeking?

Have you ever made a complaint or taken action against the Respondent(s), prior to this with respect to any other matter or issue?

If so, please provide details of the date of the complaint(s), the details of the matter/issue and the outcome of same.

Have you ever filed a complaint with the Equal Opportunity Commission before?

If so, please provide details of the date of the complaint(s), the Respondent(s), and the outcome of same.

How did you find out about the Equal Opportunity Commission?

Please tick as appropriate:

Media

Could you indicate whether it was a:

STATEMENT OF TRUTH

Complainant's signature
Witness's signature