NAACP Discrimination Report Form

Name *

Your name

First Name

Last Name

Phone *

(###)

###

####

Gender *

This is the beginning of the report demographics

Female

Male

Other

Prefer not to say

Race *

Check all that apply

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Age Range *

0-17

18-29

30-39

40-49

50-59

60-69

70-79

80+

What is your issue or concern about? *

Testing

Education

Child Care

Income Support

Small Business Support

Worker Safety

Criminal Justice

Other:

Is this an individual or group issue or concern? *

Individual

Group

Is your issue or concern tied to a specific company or organization? *

Yes

No