STATE OF KANSAS
KANSAS HUMAN RIGHTS COMMISSION
We are providing this complaint form, instructions, and supplemental information form as a service to the public.
However, we encourage individuals wishing to file complaints with the Kansas Human Rights Commission (KHRC) that
fall within the jurisdiction of the Kansas Act Against Discrimination and/or the Kansas Age Discrimination in
Employment Act to contact our Intake Unit. Intake staff can draft a complaint for you. Intake staff can be reached at
(785) 296-3206, toll free at 1-888-793-6874, or at (TDD) (785) 296-0245 during State of Kansas workdays from 8:00
a.m. to 5:00 p.m.
If you wish to start the employment complaint intake process at a time when KHRC offices are closed, we provide a
quick and easy on-line questionnaire. It is available on our main webpage at www.khrc.net. Scroll down to the red link
of “Interested in filing an employment complaint? Start the process an online questionnaire. Click here.”
Instructions
If you are under 18 years of age, a parent or guardian may file for you.
Part 1 Instructions: Selecting Base(s) (Protected Classes):
Please select the base(s) (protected classes) that you feel best describes the reason(s) for the alleged discriminatory
action(s) and/or harassment by doing the following:
Please check the box(es) beside the Kansas Act Against Discrimination and/or the Kansas Age Discrimination
in Employment Act. Age is only for employment complaints and when the Complainant is age 40 years old
or older. Please complete the fillable box for your age if applicable.
If you are filing under the Kansas Act Against Discrimination for an employment, housing or public
accommodations complaint, please check one or more of the bases (protected classes). Sex includes gender,
pregnancy, sexual orientation, and gender identity. Genetic Information is only for employment
complaints. Familial Status (having children or grandchildren under the age of 18 live with you) is only for
housing complaints. Depending upon which bases (protected classes) you select, there may be either a drop
down box or a fillable box beside the basis to provide additional information.
Part 2 Instructions: Alleged Date(s) of Incident(s): The alleged incident(s) must have occurred in the last six
months for employment and public accommodation complaints. If there are multiple incidents, they must not be
more than six months apart. For housing complaints, the last alleged incident(s) must have occurred within the last
year.
Part 3 Instructions: Charges Based on the Following Facts: Please provide a description of the adverse action(s)
or the harassment that you allege has occurred due to the base(s) you selected. Please provide the title(s) of the
person(s) you allege discriminated against you or harassed you. Please list your job title and when you were hired if
this is an employment complaint.
Please date and sign the complaint on the line marked by an “X”.
Submit Your Signed Complaint and Supplemental Information to the Kansas Human Rights Commission:
By e-mail to [email protected], by facsimile to (785) 296-0589, or by mail to:
Kansas Human Rights Commission
Attn: Intake Unit
900 S.W. Jackson, Suite 568S
Topeka, Kansas 66612
If you choose to submit a copy of a signed complaint by e-mail, facsimile, or mail, you are expected to retain the
original, signed complaint in your records for production to the KHRC upon request.
STATE OF KANSAS
KANSAS HUMAN RIGHTS COMMISSION
DOCKET NO.
On the complaint of
_________________________________________
(Complainant’s Full Legal Name)
Complainant,
vs.
Respondent,
__________________________________________ and its Representatives
(Respondent’s Full Legal Name)
I, ______________________________, residing at ___________________________
(Complainant’s Full Legal Name) (Address, City, State, Zip Code)
charge _________________________ and its Representatives, whose address is
(Respondent’s Full Legal Name)
_____________________________________________________________________.
(Respondent’s Address, City, State, Zip Code)
With an unlawful practice within the meaning of:
Part 1:
[ ] The Kansas Act Against Discrimination (Chapter 44, Art. 10, K.S.A.) and
specifically within the meaning of subsection of Section 44-1009 of said Act,
because of my:
RACE SEX ANCESTRY
RETALIATION RELIGION NATIONAL ORIGIN
DISABILITY
FAMILIAL STATUS
(HOUSING ONLY)
COLOR
GENETIC INFORMATION
[ ] The Kansas Age Discrimination in Employment Act (Chapter 44, Art. 11, K.S.A.)
and specifically within the meaning of subsection of Section 44-1113 of
said Act,
because of my AGE of ___________________________ and ___ Retaliation.
state your age
N/A
SPECIFY OTHER RACE HERE
N/A
MY DUE DATE IS OR WAS - LIST DATE
N/A
SPECIFY OTHER ANCESTRY HERE
MY RELIGION IS
NAME THE COUNTRY YOU WERE BORN IN
N/A
SPECIFY SKIN DISCOLORATION
STATE OF KANSAS
KANSAS HUMAN RIGHTS COMMISSION
(continued)
Docket No.
Part 2:
Alleged Date of Incident, on or about ____________________________________.
(List specific date with month, day and year or range of dates.)
Part 3:
The aforesaid charges are based on the following facts:
I have not commenced any action, civil or criminal, based upon the grievance set forth above, except
I declare under penalty of perjury that the forgoing is true and correct; and if this document is executed
out
side the state of Kansas, I declare under penalty of perjury under the laws of the state of Kansas that the
forgoing is true and correct.
I attest that I am the undersigned Complainant, or if I am not the Complainant, I am the Complainant's
attorney at law or other individual who is legally authorized to sign for and on behalf of Complainant.
Executed on ___________________
(Date)
X________________________________
(Signature of Complainant)
STATE OF KANSAS
KANSAS HUMAN RIGHTS COMMISSION
Supplemental Information
Please complete the following supplemental information:
Your Full Legal Name: ___________________________________________________
Address, City, State, Zip: ________________________________________________
Home Phone Number: ___________________________________________________
Cell Phone Number: ____________________________________________________
E-mail Address: ________________________________________________________
Work Phone Number if we may contact you there: ___________________________
Your Date of Birth: _______________________
Did the alleged act(s) of discrimination take place in Kansas? ____ Yes _____ No
If this is an employment complaint, please complete the following:
Does the employer have four or more employees? _______ Yes _______ No
Have you filed a charge of employment discrimination with the U.S. Equal
Employment Opportunity Commission (EEOC) on the same matters listed above?
____ Yes Please provide the EEOC charge number and date filed: ____________
____ No