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Tamara D. Grigsby
Civil Rights Department
Customer Complaint Form
If you need assistance in completing this form, please contact the Dane County Civil Rights Department at (608) 283-1391.
Contact Information
First Name
Last Name
Address
City
State
Zip
Home Phone
Work Phone
Email
Preferred Method of Contact
Call
Email
Complaint Description
Issues Involved
Access to Services
Discrimination
Harassment
Treatment
Other(Specify)
Issues Other
Type of Complaint
Age
Ancestry
Color
Disability
Gender
Marital Status
National Origin
Physical Appearance
Race
Religion
Sexual Harassment
Sexual Orientation
Other(Specify)
Complaint Other
What happened? (Include all important times, dates, witnesses and events)
What actions have you taken up to this point?
What actions do you wish to help resolve your complaint?
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