Complaint Form

Is this complaint service related:

Yes

No

Question 3. Why has this complaint occurred? Was it because of: (please tick a box or boxes)

your race or ethnic origin

your sex

your age

your sexual preference or characteristics (sexuality)

your marital status (married, single, or de facto)

whether you have children or not (parenthood)

your impairment (disability)

you were breastfeeding

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

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

you have a need because of your race, sex, impairment, etc, and your need was not

catered for

you have been treated unfairly because you have a guide or assistance dog

you were treated differently because you had put in a complaint

you were offended by discriminatory advertising

our service

our staff members

another service provider or agency

another service provider’s or agencies staff member

other please specify

Question 4. Where did the incident happen (please tick a box)?

employment/work

clients home

car

outing/activity

Something not listed here - please explain: