Discrimination Complaint Form

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Please correct the field(s) marked in red below:

If you believe you have suffered discrimination in a City facility or program because of race, veteran's status, color, age, disability, gender, national origin, or low income status, please fill out this form completely and click Submit. The form will be sent to the City of Newton's Human Resources Director. If you do not wish to use the online form, you may download and print the form here: Discrimination Complaint Form or contact the HR Department at dperbeck@newtonkansas.com

Name:
Address:
City, State, Zip:
Phone Number:
Are you filing this complaint on your own behalf?
 *
Are you filing this complaint on your own behalf?
If not, please supply the name and relationship of the person for whom you are submitting a complaint:
Please explain why you have filed for a third party:
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party:
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party:

Description of your complaint:

 *

Have you previously filed a discrimination complaint with the City of Newton?

Have you previously filed a discrimination complaint with the City of Newton?
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?
If yes, check all that apply:
If yes, check all that apply:
Please provide information for a contact person at the agency/court where the complaint was filed:

If you have any questions about the City of Newton's policies and procedures related to discrimination or civil rights violations, please contact Human Resources Director Debra Perbeck at 316-248-3640 or dperbeck@newtonkansas.com.

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