Instructions for Intake Form

Fill out the intake form as completely as possible.  Use the comment area to explain exactly what happened to you. Be specific with all names and dates.

NOTE: Completing this Intake Questionnaire does not necessarily mean that a complaint of discrimination has been filed.  After we receive the information you provide, the Intake Officer will either type a complaint of discrimination and send it to you for your review and notarized signature or, if the information is not sufficient to draft a complaint, call you to discuss your allegations further.

A PERFECTED COMPLAINT OF DISCRIMINATION IS FILED WITH THE MAINE HUMAN RIGHTS COMMISSION WHEN A SIGNED, NOTARIZED COMPLAINT FORM IS RECEIVED BY THE COMMISSION. COMPLAINTS MUST BE RECEIVED BY THE COMMISSION WITHIN THREE HUNDRED (300) DAYS OF THE ALLEGED ACT OF DISCRIMINATION.

NOT ALL DISCRIMINATION IS UNLAWFUL! The Maine Human Rights Act makes it unlawful to discriminate in the following areas for the following reasons:

EMPLOYMENT HOUSING ACCESS TO PUBLIC ACCOMMODATION CREDIT EXTENSION EDUCATION
Age -- -- Age --
Ancestry Ancestry Ancestry Ancestry --
National Origin National Origin National Origin National Origin National Origin
Race Race Race Race Race
Color Color Color Color --
Religion Religion Religion Religion --
*Sex Sex Sex Sex Sex
Sexual Orientation Sexual Orientation Sexual Orientation Sexual Orientation Sexual Orientation
Mental disability Mental disability Mental disability -- Mental disability
Physical disability Physical disability Physical disability -- Physical disability
Worker’s Comp Retaliation for filing with previous employer only. **Receipt of Public Assistance Children (lodging only) Marital Status --
Whistleblower’s Retaliation Familial Status -- -- --
Genetic Predisposition -- -- -- --

Retaliation:  The Maine Human Rights Act prohibits retaliation against any individual who has opposed any practice which would be a violation of the Act,or because the individual has made a complaint, testified or assisted in any manner in any investigation proceeding or hearing under the Act.

* Note:  Sexual harassment is a form of sex discrimination.

**Note: Receipt of Public Assistance means status as a recipient of federal, state or local public assistance

(Revised May 2012)