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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