Northern Territory Anti-Discrimination Commission (ADC)

Complaint Form

All formal complaints to the NT Anti-Discrimination Commissioner must be in writing. If you are having trouble filling out this form, go to the nearest Legal Aid office, Community Legal Service or contact the Anti-Discrimination Commissioner’s Office.

Telephone:
Phone:(08) 8999 1444 or 1800 813 846 (freecall)
Fax:(08) 8981 3812
TTY:(08) 8999 1466
Email: complaintadc@nt.gov.au

Postal:
LMB 22 GPO
Darwin NT 0801

This complaint form is also available as an Adobe Acrobat or Microsoft Word file for you to download and print if you prefer.

You might also like to refer to our pamphlet "How we deal with complaints".

Please note that the fields in the form below that are marked in bold with an asterisk are required fields. You will not be able to submit the form if you have not entered the required information.


Question 1
First name *
Last name *
Postal Address Line 1 *
Postal Address Line 2
City/Town *
State *
Postcode
Telephone - Work
Telephone - Home
Telephone - Mobile
Fax
Email

We would appreciate you answering the following for our records.

Are you		From a non-English speaking background (NESB)
		Female
		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?		Yes No
Employer's name if work related:
Their Postal Address
City/Town
State
Postcode
Telephone
Fax

Question 3
Why do you think you were treated unfairly?
Was it because of: (Please		your race or ethnic origin
tick a box or boxes)		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

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
		an advertisement may be discriminatory
		you have been treated badly 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
Please give a detailed description of your complaint. (Tell us what happened, where, when and who was involved.)



Question 6
It is important to show that you were treated unfairly because of an attribute you have ticked at questions 3a & 3b. Explain why you think the way you were treated was based on your attribute. (Unless you already explained this in question 5).



Question 7
Have you talked to another organisation about this? If so, write the name of the organisation and the person you dealt with there:



Question 8
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 9
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 10
What effect (financial or personal) did the unfair treatment have on you?



Question 11
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 12
Do you have any documents or anything else that has anything to do with your complaint? Please attach a photocopy.



Question 13
List anything else you think we may need to know here.




		Thank you