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2. Tell Us About Your Complaint
4. Date the alleged discrimination occurred*
   Date the alleged discrimination occurred

   Date the alleged discrimination occurred
   (If the discrimination occurred on more than one occasion, then provide the date of the most recent occurrence.)
6. Classification of the party against whom you are filing your complaint*

   1. County employee
   2. County service or policy
8. The alleged discrimination happened because of one or more of the following Frederick County protected categories*

   1. Race
   2. Color
   3. National origin OR Ancestry OR Language

   1. Age
   2. Religion
   3. Sex (including Gender Identity or Sexual Orientation)

   Check all that apply
10. For complaints of discrimination regarding Disability, complete the Disability complaint form at
    Frederick County, Maryland - ADA - Complaint/Grievance Form
12. Please describe why you believe these actions were taken against you and how they are related to your protected class. Describe the incident that occurred, or the situation which you feel qualifies as discriminatory act, practice, or policy.*
14. Is the discrimination still occurring?*

    1. Yes
    2. No
16. Name and address of government agency or place where the discrimination happened*
18. Add an additional person or agency
    If needed
20. Is the person filling out this complaint the same person against whom the alleged discrimination occurred?*

    1. Yes
    2. No
22. Enter your: Name, Phone Number, Email address in the box below if you answer “No” to this question
26. INFORMATION CONCERNING THE PERSON AGAINST WHOM THE ALLEGED DISCRIMINATION OCCURRED
28. First Name*
29. Last Name*
31. Address1*
33. Address2
35. City*
36. State*
37. Zip*
39. Phone*
    Primary
40. Phone
    Secondary
42. Email Address*
44. Upload or Drag files here which provide information or documentation that support your claim of discrimination
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field