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______________________________________________________________________ <br /> <br />Where did the discrimination occur? <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br /> <br />When did the discrimination occur? <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br /> <br />Were there any other witnesses to the discrimination? <br /> <br />Name Organization/Title Work <br />Telephone <br />Home <br />Telephone <br /> <br /> <br /> <br /> <br />How would you like to see this situation resolved? <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br /> <br />Have you filed your complaint, grievance, or lawsuit with any other agency or court? <br />Who ______________________________________ When ______________________ <br />Status (pending, resolved, etc.) _________________ Result, if known ______________ <br />Complaint or case number, if known _________________________________ <br /> <br /> <br />If you have an attorney in this matter, please provide their contact information: <br />Name_________________________________ Phone____________________ <br />Address___________________________________ City______________ Zip_______ <br />