Proposal Form – Employment - Human Rights Commission

Complaint File Number*

You find this number on the Complaint Form that was sent to you.

Complainant's full name*

First Last

Complainant's email address*

Briefly explain how the discrimination or harassment negatively affected you*

Describe how your feelings, health, relationship with others, and etc. were impacted.

What do you need to happen to resolve the complaint?*

If other, please specify

Do you want to prevent the discrimination or harassment from happening to others (public interest remedies)?*

Yes

Yes, I want the Respondent to...

If other, please specify

Do you want monetary compensation for the injury to your dignity, hurt feelings and self-respect (general damages)?*

Yes

If you are claiming general damages, insert amount

Did you suffer any lost wages?*

Yes

If you suffered lost wages, please answer the following questions to help calculate your loss:

First date you worked

Last date you worked

Your gross weekly salary at your previous job (before taxes)

Your weekly net salary at your previous job (after taxes)

Amount you received from your employer upon termination

For example, pay in lieu of notice or severance payment.

Any amount you received in Employment Insurance or other benefits since your previous job (weekly)

The number of weeks you received EI or other benefits

If you have found another job, what date did you start your new job?

Your weekly net salary at your new job (before taxes)

Your gross weekly salary at your new job (after taxes)

What did you do to mitigate the harm?

Briefly describe what you have done to limit the financial harm caused by the discrimination or harassment. For example, if you get fired, you have to make reasonable efforts to try to find another job so that you reduce your financial losses. This may mean taking lesser-paid work or expanding the job search area.

Attach receipts and/or any documents to prove your claim.

Drop files here or

Accepted file types: jpg, jpeg, pdf, png, doc, docx, Max. file size: 10 MB, Max. files: 5.

The Human Rights Commission's mediator will review your Proposal Form. The following can happen:

You may need to provide further documents to prove your claim.
The mediator will calculate your proposed financial loss and help finalize the Proposal.
The final Proposal Form will be sent to the Respondent(s).

Agreement

I have*

read about the mediation process on the Human Rights Commission's website.

I understand*

that I must participate in the process and keep in contact with the Human Rights Commission. If I fail to participate, my complaint may be closed.

I understand and agree*

with the Human Rights Commission's privacy policy

This Proposal Form*

is complete and true to the best of my knowledge, belief and ability.