Human Rights Application Form The Complaint Process Human Rights Application Form Reply Form Rebuttal Form Frequently Asked Questions YOU DO NOT HAVE AN OFFICIAL COMPLAINT YET. The Human Rights Commission will review the information you provide in the Human Rights Application Form to determine if we can accept your complaint. You will be notified of our decision once we have received and reviewed your completed Application Form. You may be asked to provide further information. You do not need a lawyer to fill out the Human Rights Application Form. Get help from family, friends or another support person, if you wish. BEFORE YOU START - READ THROUGH THIS APPLICATION FORM, THE ACCOMPANYING GUIDE AND THE COMPLAINT PROCESS PAGE FIRST. Once you’ve read everything and familiarized yourself with the process, collect any information you think might be important (letters, emails, dates etc.) so that you can easily reference it while filling out the Application Form. You will not be able to save this document while filling it out. You can either fill it out all at once or answer the questions in a separate word document and then cut and paste your answers back into the Human Rights Application Form. * Required Name*Are you filling this Application Form out using your own name, but on behalf of someone else?YesNoWe will need the other person’s consent prior to deciding if we can accept the complaint. Commission staff will get this information from you later.Address* Street Address Address Line 2 Town / City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Email Address* Telephone Number*2. What is the best way to contact you and/or send you information?*If you check email, you are consenting to the delivery of documents by email. PhoneEmailFaxMail3. Who are you complaining about? (This person is called the Respondent)*Name of company, business, organization, association or person.Check your paystub, T4, rental agreement, contract or company website for the official name. Find more information about how to find the correct name hereAddress* Street Address Address Line 2 Town / City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Telephone Number*Name of the owner/head of the company, business, organization or associationIs there a specific person in the company, business, organization or association that you are complaining about?If applicable, name the specific person in the company, business, organization or association that you are complaining about.4. Is there another company, business, organization or association that you are complaining about? (This person is called the Second Respondent)YesNoWho else are you complaining about?*Name of company, business, organization, association or person. Check your paystub, T4, rental agreement, contract or company website for the official name.Address* Street Address Address Line 2 Town / City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Telephone Number*Name of the owner/head of the company, business, organization or associationName of company, business, organization, association or person. Check your paystub, T4, rental agreement, contract or company website for the official name.Owner/Head’s email address (if known) Is there a specific person in the company, business, organization or association that you are complaining about?Name of co-worker, manager or supervisor who discriminated or harassed you.5. Where in Newfoundland and Labrador did the discrimination or harassment take place?*Name the specific city or town. This must be in Newfoundland and Labrador.Learn more about why the discrimination or harassment must take place in Newfoundland and Labrador here6. When did the incident you are complaining about happen?*Don’t worry if you can’t remember the exact date. Give us your best estimate of when the discrimination or harassment happened.The last incidence of discrimination or harassment must have happened in the last year. Learn more about the one-year limitation period here 7. Is the discrimination and/or harassment still happening?*YesNo8. The following is a list of prohibited grounds. Check the box beside each ground that you believe applies to you. You can check more than one box.*For definitions refer to our FAQ.For example:I am 68 years old and didn’t get a promotion. You would check age.I have asthma and was not accommodated. You would check disability or perceived disability.I am a woman and was fired when I disclosed my pregnancy. You would check sex (including pregnancy).I am a Canadian of South Asian or African descent and I wasn’t able to rent an apartment. You would check race, colour and/or ethnic origin. Disability (physical and mental and including perceived disability) Colour Ethnic Origin Religious Creed Age Sex (including pregnancy) Gender Identity Marital Status Source of income Criminal Conviction (employment only) Nationality Social Origin Religion Disfigurement Sexual Orientation Gender Expression Family Status Political Opinion 9. Describe what happened to you?*Tell your story in chronological order. It might be easier to start at the beginning and end with the last incidence of discrimination and/or harassment.Use point form if it is easier.Explain with specific examples and include the following:What happened?Who was involved (include names)?When it happened (day/month/year)?Where it happened?Were there any witnesses?Find examples of how to fill out this section here10. Why do you feel that the discrimination or harassment you experienced is based on one or more of the prohibited ground(s) you checked in Question 8?*You must provide specific examples of why you feel this way. Was something said to you? Or was it just a feeling that you had? Were you the only one treated this way?Find examples of how to fill out this section here 11. Tell us how what happened (as described in Question 9) negatively impacted you?*Find examples of how to fill out this section here 12. Have you tried to resolve this on your own?*What have you done to try to resolve this problem? Who did you speak to? What happened? How were things left? Find out more about how to resolve this problem on your own hereHow were things left?13. Have you taken any other action related to your complaint?*Have you filed a union grievance, started a court action or another action? What is happening in this other action? Attach any documents that show what you’ve done in the other action. 14. The Commission tries to help the parties resolve the complaint. We strongly encourage the parties to attempt the Voluntary Resolution Path (VRP) or Mediation. If your complaint is accepted, are you interested in speaking to the Commission’s mediator?*VRP is a faster alternative to the normal human rights investigatory route. The majority of complaints that enter VRP are resolved within 2-3 months. The process is completely voluntary and confidential. The parties, with the help of the Commission’s mediator, control the process and the outcome. Mediations can be either informal (a phone call or email) or formal (a face to face meeting). There is no cost to participate in VRP/mediation. For more information on VRP/mediation refer to our FAQ.YesNo15. Remedies. What do you need to happen to resolve your complaint?*Think about why resolving this complaint is important to you. Be brief and use point form if it is easier. If your complaint is accepted, you will be able to give us more information later. For example: I need a specific accommodation, such as a new desk at work, a ramp in my apartment building or time off work for a religious reason. I don’t want this to happen to other people. I want the person I’m complaining about to introduce an anti-discrimination/harassment policy and do human rights training. I want to find another job and move on. I need an apology or a letter of reference. I lost money or was forced to spend money on certain items, such as lost income, increased rent or moving expenses. I am looking for money to compensate me for injury to my dignity, feelings and self-respect. For more information about remedies refer to our FAQ. 16. Please attach any documents that may be relevant to this complaint.Learn how to attach documents here. Drop files here or 17. Is there anything else you would like to tell us?What happens next? The Commission will review your Human Rights Application Form to determine if we can accept your complaint. One of the following can happen: The Human Rights Application Form is complete and can be accepted for filing. We will confirm any edits made to your form with you before a copy of the complaint is sent to the person you are complaining about. The Human Rights Application Form is incomplete and no decision is made about acceptance. You will be asked to provide further information by a certain date, OR The Human Rights Application Form is not accepted for filing. You will be told why your complaint was not accepted. Agreement* I declare that the information in this Human Rights Application Form is true to the best of my knowledge and belief. If your complaint is accepted, this Application Form may be disclosed to the Respondent(s) if required to conduct an investigation or allow the other party to respond to the complaint. Your personal contact information will not be given to the respondent(s) or any person or organization outside the Commission unless required by law (e.g. Access to Information and Protection of Privacy Act.)The collection and disclosure listed above is authorized under sections 61(c) and 68(1)(b) of the Access to Information and Protection of Privacy Act, 2015. If you have any questions regarding this collection or disclosure please contact the Human Rights Commission at 729-2709 or 1-888-563-5808. NameThis field is for validation purposes and should be left unchanged.