American-Arab Anti Discrimination Committee
1732 Wisconsin Ave, N.W, Washington, DC 20007
Tel: (202) 244-2990, Fax: (202) 244-7968. Email: adc@adc.org
Incident Report/Discrimination Claim
Please fill out this form clearly, describe the incident with enough information so we can better understand your complaint. The information you provide will remain confidential during the investigation and verification of the incident.
*
- indicates required field
*
Name
Address
City
State
Zip-Code
*
E-mail
Incident Information
*
Category of Discrimination
Education
Employment
Entertainment
Law Enforcement
Media
Religious
Sexual Orientation
Other
*
Cause/Reason of Discrimination
Age
Color
Gender
National Religion
Race
Religion
Sexual Orientation
Other
Incident Reported to
*
Date Of incident (approximate date)
Time of Incident
*
Address/Location Of Incident
Involved Party Name(s)
*
Would you be willing to talk to the Media?
Yes
No
Please Use the following space to describe the incident(s)
