Please return this form to the commission. If you prefer to mail it to us our address is:

The Pullman Human Rights Commission
P.O. Box 3074 CS
Pullman, WA 99163

-------------------------------------------

Incident Reporting Form (Please print)
 
 

Case Number:___________

Date:__________________


Name:__________________________________________

Address:_______________________________________

Phone:_________________________________________

Email:_________________________________________
 

Nature of Complaint/Report
 

___ Personal (involves an individual)
___ Institutional (involves Federal, State, County or City entity or educational institution)
___ Business (involves an area business)
___ Organizational (involves an area agency, civic group, or non-profit organization)
___ Other, please define: ____________________________________________________________________
Type of Complaint/Report

___ Age
___ Disability
___ Gender expression
___ Income/class
___ Marital status
___ National/ethnicity
___ Race
___ Religious affiliation
___ Retaliation
___ Sexual harrassment/gender harrassment
___ Sexual identity
___ Other:_______________________________
 

Please describe the incident. (attach separate sheets of paper if neccessary)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Resolution of Complaint/Report
___ I would like my name to be kept confidential
___ I do not care if my name is kept confidential

Please check an appropriate category:
___ (A) I would like to meet with the Commission to discuss my case.
___ (B) I would like to Commission to help me contact and speak with the appropriate agency (including law enforcement) about this case.
___ (C) I would like the Commission to be aware of this situation and to have the Commission use the information as they see it.
___ (D) I would like the commission to be aware of the situation, but do not wish to have the Commission take any further action.

Prior to contacting the Pullman Human Rights Commission, 

(please check an appropriate category)

___ I contacted area law enforcement.

___ I reported this incident by calling 332-BIAS.

___ I filed for grievances through institutional procedures.

___ I filed a complaint to another agent. Please describe:______________________

___ I have not told anyone about this report.
 

What would you consider an appropriate solution to your complaint? (attach additional sheets if necessary)
 
 








PHRCís Response to Case Number:_________________________________________________

Date Received:______________________________  Date Completed:_____________________
 
PHRC designated contact person for this case:__________________________________
 

Category (A)           

Person filing the report wanted to meet with the PHRC.

PRHC met with the person on this date ______________

PRHC members present at the meeting:
 

Complainantís Report/Issues Discussed:
 
 
 
 
 
 

Action Taken by PHRC:
 
 

Category (B)   

PHRC assisted in contacting appropriate agency about this issue.

Agency/Agencies Contacted:  (when & who)
 
 
 

PHRC Comments:

  
 
 
 
 
 

Category (C)  
 
Person filing the report wanted the PHRC to be aware of the situation and to use the information however the PHRC felt was appropriate.
 

PHRC Comments/Actions:
 
 

Category (D) 
 
Person filing the report required no action on the part of PHRC.
PHRC contacted the person and acknowledged receiving the report.

PHRC comments:
 
 
 
 
 
 
 
 

The person filing this report indicated the following desired solution to the issue:
 
 
 
 
 
 

PHRC summary & final resolution of this case:  (attach additional sheets if necessary)