Form Center

Brookline Discrimination Report Form

2. Last Name
   Check below if you wish to remain anonymous.
4. Anonymous

   1. Anonymous
6. First Name
8. Contact Phone Number*
   Leave blank if filing anonymously
10. Date of Incident*
    Date of Incident

    Date of Incident
12. Compliant Type*
    -- Select One --Racial/EthnicityReligious Sexual OrientationGenderHousingGeneticsNational OriginUnprofessional BehaviorAgeDisability
14. Subject of Complaint*
16. Subject of Complaint Type *
    -- Select One --Town/Non-Government Business or ServiceTown Department/OrganizationSchool Department
18. Complaint Details *
20. Actions Taken
22. Incident Resolution Details
24. Resolution Date
    Resolution Date
26. Complainant Informed of Resolution

    1. Yes
    2. No
28. Complainant Satisfied

    1. Yes
    2. No
30. Follow-Up
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field