Question 1
First name *
Last name *
Postal Address Line 1 *
Postal Address Line 2
City/Town *
State *
NT
WA
SA
VIC
NSW
QLD
ACT
TAS
Postcode
Telephone
Work
Fax
Email
We would appreciate you answering the following
for our records.
Are you
Male
From a non-English speaking background (NESB)
Aboriginal/Torres Strait Islander
Impaired (physical/intellectual/mental disability)
Question 2
Who do you think treated you unfairly?
Business/Organisation/Agency:
The person's name (if known)
Their position (if known)
Is this complaint work related?
Employer's name if work related:
Their Postal Address
City/Town
State
NT
WA
SA
VIC
NSW
QLD
ACT
TAS
Postcode
Telephone
Fax
Question 3
Why do you think you were treated unfairly?
3a. Was it because of: (Please select at least one)
your race or ethnic origin
your sex
your age
your sexual preference or characteristics (sexuality)
your marital status (married, single, or defacto)
whether you have children or not (parenthood)
your impairment (disability)
you were breastfeeding
your trade union membership or non-membership
your religious beliefs
your political beliefs
your medical or criminal records which are irrelevant to your situation
your pregnancy
your association with someone who has, or is believed to have, one
of the above listed attributes
3b. We also look at complaints where the following things
may have happened
you were sexually harassed
you were harassed because of your race, impairment, sexuality or
parenthood etc.
you were asked questions about yourself which were unnecessary and
upon discrimination might be based
you have a special need because of your race, sex, impairment, etc,
and your special need was not catered for
you have been treated unfairly because you have a guide or assistance
dog
someone has tried to help someone contravene the Anti-Discrimination
Act
you were treated differently because you had put in a complaint
to the Anti-Discrimination Commissioner or you were a witness for
someone who put in a complaint to the Anti-Discrimination Commissioner.
Question 4
Where did the unfair treatment happen (please tick
a box)?
employment/work
when you tried to get food, drink, cars, clothes, or anything that
is legal to buy, rent or lease (supply of goods, services and facilities)
education
accommodation
club membership
superannuation/insurance
Something not listed here - please explain:
Question 5
It is important to show that you were treated unfairly because of an attribute you
have ticked at questions 3a & 3b. Explain what happened and why you think the way you were treated was
based on your attribute. (Unless you already explained this in question 5).
Question 6
Have you talked to another organisation about this? If so, write the name of the
organisation and the person you dealt with there:
Question 7
Have you tried to talk to who you are complaining about or have you tried to sort out
this complaint in any other way? If you did, write what happened here:
Question 8
Did these things happen within the last 6 months? (We may not be able
to deal with matters that occurred more than 6 months ago). If so, please fully explain
the reasons why you delayed making the complaint.
Question 9
What effect (financial or personal) did the unfair treatment have on
you?
Question 10
Do you know anyone who saw the unfair treatment and is willing to help you with your complaint? If so, write their names and contact phone numbers here:
Question 11
Do you have any documents or anything else that has anything
to do with your complaint? Please attach a photocopy.
Question 12
List anything else you think we may need to know here.
Thank you
