Are you complaining on behalf of someone elseYES / NO
If yes, what is their name? ________________________________________________________
What is your relationship to that person? ________________________________________
2.Who do you think has discriminated against you? Person’s name_____________________________________________________________
What is this person’s relationship to you? (E.g. boss, real estate agent, insurance company) ______________________________________
Their address __________________________________________________________________
Their phone number__________________________________________________________
The organisation they work for ______________________________________________
The organisation’s address ___________________________________________________
The organisation’s phone number____________________________________________
The head of the organisation (if you know)_________________________________
This person’s position (e.g. Managing Director, Chief Executive Officer) ____________________________________________________________________
Please note that if you want to complain about an individual’s behaviour and that person is employed by someone else, details about their employer is needed.
If it happened at work also list:
your position or job ;
the correct name and address of your employer (from your pay slip or pay office, or from the Australian Taxation Office);
the name and position of your supervisor or manager;
how long you have been employed there; and
if there are six or more employees working for your employer.
3. Where did the alleged discrimination happen? Which workplace, company, registered club, trade union, rented accommodation, shop, service, or public place etc? __________________________________________________________________________________________________________________________________________________________________________________________________________
4. When did the alleged discrimination or harassment happen? As closely as you can remember – what was the day, month, and year of each time you believe you were treated unfairly. It began on________________________________________________________________
It finished on _______________________________________________________________
Is it still going on? (Please circle)YES/NO
5. What happened? What did you do about it at the time? What happened to make you think that you have been discriminated against or harassed? Please list: §what happened; §what kind of discrimination you think it is ; §why you think it is discrimination; §who was responsible for what happened and what their relationship is to you; §whether you have done anything else to sort out the problem. For example, have you complained to someone at your work, to a service provider, an industry association, a government department, a union, the Office of Industrial Relations, a lawyer or the police?If so, write down the name, position, or job title of any person you reported the unfair treatment to, and what happened)
If more than one thing happened to make you think you have been discriminated against, please list what happened each time in the order the things happened in and when it happened. Include any evidence you have to support your claim of discrimination. For example:
a copy of any poster, notice, letter or anything else you feel is unfair to you;
anything else that supports what you say, e.g. a photograph, emails, letters.
a note you made at the time in your diary or on a piece of paper;
a copy of anything that shows how someone else in a similar position to you has been treated differently to the way you were treated;
anyone else who saw or heard the discrimination and is willing to provide details. Ask them to give you a written statement of what they saw or heard;
If you need more space to explain fully what happened, please add your own extra pages.
6.Is there anyone else helping you with this complaint?(For example, your union, a lawyer or a community worker)
What is their name?______________________________________________________
Who are they?____________________________________________________________
Their phone number_____________________________________________________
What are they doing to help you?
7. What would you like to happen to sort out this complaint? This is called a “settlement proposal” and will help to decide how your complaint is dealt with.You may ask for any reasonable solution to resolve the unfair treatment you think you received, such as:
getting your job back – or a transfer, promotion, or extra training;
getting whatever you were previously refused – e.g. accommodation, a loan you applied for, admission to a course;
changes to policies and procedures to make sure the discrimination does not happen again to anyone else, for example introducing an equal opportunity policy in the workplace;
education programs in the workplace or organisation involved, so that everyone there knows what discrimination is, how to prevent it, and what to do if it happens to them or to anyone else;
compensation (money) paid for any money you have lost (such as wages), or for damages or hurt feelings;
a donation to a charity of your choice; or
anything else that might make up for the unfair treatment.
8. Is your complaint urgent?YES/NO (please circle) Complaints are usually handled in the order that they are received.Say if you have an urgent complaint, for example you are about to lose your job or your accommodation.
9. Sign and date your complaint
Your signature ________________________________Date________________________________
If you are complaining on behalf of someone else, their signature ______________________________________________ Date _________________________________
This information is intended as a general guide only and you should obtain legal advice if you have specific questions.