2. This is the bias incident form for the Town of Acton. Please note that correspondence with the Town of Acton and its Department of Diversity, Equity and Inclusion (DEI) is public. You may call to speak confidentially with the DEI Director about your options before filing a complaint. If you an unable to immediately reach the DEI Director they will return your call within 24 hours.
4. Complainant (You)
6. Name:*
8. Address:*
10. Town/City:*
11. State:*
12. Zip Code:*
14. Phone:*
15. Alternative Phone:
16. Email:*
18. Respondent (the person you feel violated your rights)
20. Name:
21. Name of business: (if applicable)
23. Address:
25. Town/City:
26. State:
27. Zip Code:
29. Phone:
30. Alternative Phone:
31. Email:
33. What area do you believe your rights were violated? (check all that apply)

    1. Employment
    2. Education
    3. Housing
    4. Public Accommodation*
    5. Services
    6. Credit/Lending
    7. Recreation
    8. Public Area
35. Other (specify):
37. * Public accommodations are places open to and accepting the patronage of the general public. Some examples include: hotels, restaurants, theaters, sports stadiums, houses of worship, stores, gas stations, funeral parlors, employment agencies, banks, hospitals, nursing homes, pharmacies, libraries, transportation vehicles and stations, parks, zoos, child care centers, homeless shelters, food banks, adoption agencies, gyms, beaches, and providers of professional services such as lawyers, doctors, dentists, accountants, and insurance agents.
39. Additional Information:
    Public accommodation civil rights protections
41. Why do you believe your rights were violated? (check all that apply)

    1. Race
    2. Ethnicity
    3. Color
    4. Religious Views
    5. National Origin
    6. Citizenship
    7. Age
    8. Ancestry
    9. Family/Marital Status
    10. Disability
    11. Military Status
    12. Source of Income
    13. Sex
    14. Sexual Orientation
    15. Gender Identity or Expression
43. Other (specify):
45. Please summarize how you feel your human rights were violated.*
47. Supporting documentation: (pictures, emails/correspondence, websites etc)
49. OPTIONAL: What remedy are you seeking? (How do you want us to help?)
51. If another agency is investigating this incident, which one(s)? (Check all that apply.)

    1. None
    2. United States Equal Employment Opportunity Commission (EEOC)
    3. Massachusetts Commission Against Discrimination (MCAD)
    4. Massachusetts Attorney General
    5. Massachusetts Department of Education
53. Other (specify):
Leave This Blank:


54. Submit

* indicates a required field