Northern Territory

Anti-Discrimination Commission

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Complaint form

All formal complaints to the NT Anti-Discrimination Commission must be in writing. If you require assistance in completing this form, contact the Anti-Discrimination Commission or go to the nearest Legal Aid Office or Community Legal Centre.

Please note that the fields in the form below that are marked 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

Full name: *

Postal address: *

State: *

Postcode: *

Telephone:
Work:  
Home:
Mobile:

Fax:

Email:

We would appreciate you answering the following for our records.

Gender:
Male
Female
X

Are you:
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?
Yes
No

Employer's name if work related:

Postal address (include city/town, state and postcode):

Phone:

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?
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

If other, 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.

Question 6

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

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, please explain what happened.

Question 8

Did these things happen within the last twelve months? We may not be able to deal with matters that occurred more than 12 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, provide their names and contact phone numbers.

Question 11

Do you have any documents or anything else that has anything to do with your complaint? Please send documents via email.

Question 12

List anything else you think we may need to know.