Form 1190-NEW Reporting Portal for Civil Rights Violations

Contact 

You are not required to provide your name or contact information. If you want to remain anonymous, leave this section blank. If you 
choose to provide your contact information, we will only use it to respond to your submission. Learn more about our privacy policy.  

Your n​ame 
● First name ​(Optional) 
● Last Name ​(Optional) 

Contact information 
● Email address ​(Optional) 
● Phone number ​(Optional) 
● Mailing Address 1 (​Optional) 
● Mailing Address 2 ​(Optional) 
● City ​(Optional) 
● State ​(Optional) 
● Zip code ​(Optional) 

Are you now or have ever been an active duty service member? 
If you’re reporting on behalf of someone else, please select their status. 
● Yes 
● No

Example of visual styling 

Primary concern 

What is your primary reason for contacting the Civil Rights Division? 

Example of visual styling

Select the reason that best describes your concern. Each reason lists examples of civil rights violations that may relate 
to your incident. In another section of this report, you will be able to describe your concern in your own words. 

Workplace discrimination or other employment-related problem 
EXAMPLES 
● Fired, not hired, or demoted for reasons unrelated to job performance or qualifications 
● Retaliated against for reporting discrimination 
● Inappropriately asked to provide immigration documentation 

Housing discrimination or harassment  
EXAMPLES 
● Denied housing, a permit, or a loan based on personal characteristics like race, sex, and/or having children under 
18 years old 
● Denied an accommodation for a disability, including not being allowed to have a service animal 
● Harassment by a landlord or another tenant, including sexual harassment 

Discrimination at a school, educational program or service, or related to receiving education 
EXAMPLES 
● Harassment based on race, sex, national origin, disability, or religion 
● Denied admission or segregated in an education program or activity 
● Denied educational accommodations for a disability or language barrier  

Voting rights or ability to vote blocked or affected 
  EXAMPLES 
● Blocked or prevented from registering to vote, obtaining or submitting a ballot, having your ballot counted, or 
entering a polling place to vote  
● Denied ​adequate voting assistance or ​accommodations for a disability at a polling place 
● Restricted or prevented from participating in an election, including voting, becoming a candidate, or being 
elected for office   

Mistreated by police, law enforcement, or correctional staff​ (including while in prison) 
EXAMPLES 

●
●
●
●

Police brutality or use of excessive force, including patterns of police misconduct 
Searched and arrested under false pretenses, including racial or other discriminatory profiling 
Denied rights while arrested or incarcerated 
Denied access to safe living conditions or accommodations for a disability, language barrier, or religious practice 
while incarcerated. 

Discriminated against in a commercial location or public place 
This could include a store, restaurant, bar, hotel, place of worship, library, medical facility, bank, courthouse, government 
building, public park or street, as well as online. 

EXAMPLES 
● A physical or online location that does not provide disability accommodations 
● Denied service or entry because of a perceived personal characteristic 
like race, sex, or religion 
● Threatened or harassed while seeking or receiving reproductive health services   

Something else happened 
The examples above reflect some but not all of the civil rights violations that we address. Select this option if you don’t 
see an example that applies to your situation. You will be able to tell us more later.  

Primary Concern (continued) 

Hate
crimes and human trafficking 
Please let us know if you would describe your concern as either a hate crime or human trafficking. This information can 
help us take action against these types of violations. We will contact you about the next steps. We also encourage you 
to contact law enforcement if you or someone else is in immediate danger. 
Please select if any apply to your concern ​(optional)
● Physical harm or threats of violence based on race, color, national origin, religion, gender, sexual orientation, gender identity,
or disability

Example of visual styling 

● Coerced or forced to do work or perform a sex act in exchange for something of value 

[If the user flags Something Else Happened when selecting primary concern] 

Location details 

Please tell us the city, state, and name of the location where this incident took place. This ensures your concern is 
reviewed by the right people within the Civil Rights Division.​ ​Learn more about our privacy policy. 

Where did this happen? 

● Location name 
[Generic] Examples: Name of business, school, intersection, prison, polling place, website, etc.   
● Street address 1 (​optional) 
● Street address 2 (​optional) 
● City/town 
● State  

Example of visual styling 

[If the user flags their primary concern as employment-related] 

Location details 

Example of visual styling 

Please tell us the city, state, and name of the location where this incident took place. This ensures your concern is 
reviewed by the right people within the Civil Rights Division.​ ​Learn more about our privacy policy. 

Did this happen at a​ private or public employer? 
● Public employer 
Public employers include organizations funded by the government like the military, post office, fire department, 
courthouse, DMV, or public school. This could be at the local or state level. 
● Private employer 
Private employers are business or non-profits not funded by the government such as retail stores, banks, or 
restaurants. 
● I’m not sure 

How large is the employer? 
● Less than 15 employees 
● 15 or more employees 
● I’m not sure 

Where did this happen? 
● Location name 
[Generic] Examples: Name of business, school, intersection, prison, polling place, website, etc.   
● Street address 1 (​optional) 
● Street address 2 (​optional) 
● City/town 
● State  

[If the user flags their primary concern as housing-related] 

Location details 

Please tell us the city, state, and name of the location where this incident took place. This ensures your concern is 
reviewed by the right people within the Civil Rights Division.​ ​Learn more about our privacy policy. 

Where did this happen? 

● Location name 
[Generic] Examples: Name of business, school, intersection, prison, polling place, website, etc.   
● Street address 1 (​optional) 
● Street address 2 (​optional) 
● City/town 
● State  

Example of visual styling 

[If the user flags their primary concern as education-related] 

Location details 

Example of visual styling 

Please tell us the city, state, and name of the location where this incident took place. This ensures your concern is 
reviewed by the right people within the Civil Rights Division.​ ​Learn more about our privacy policy. 

Did this happen at a public or private school, educational program or activity? 
Educational programs or activities include training programs, sports teams, school clubs, or other school-sponsored 
activities. 
● Public school or educational program 
● Private school or educational program 
● I’m not sure 

What is your relationship to the person(s) affected? 
● I’m a student 
○ Are you 18 years old or over? 
■ Yes, I’m 18 years old or older 
■ No, I’m younger than 18 years old 
● I’m a parent or guardian 
● I’m a staff member 
● Other (please describe) 

Where did this happen? 
● Location name 
[Generic] Examples: Name of business, school, intersection, prison, polling place, website, etc.   

● Street address 1 (​optional) 
● Street address 2 (​optional) 
● City/town 
● State  

[If the user flags their primary concern as voting-related] 

Location details 

Please tell us the city, state, and name of the location where this incident took place. This ensures your concern is 
reviewed by the right people within the Civil Rights Division.​ ​Learn more about our privacy policy. 

What kind of election or voting activity was this related to? 
● Federal 
Presidential, congressional 
● State or local 
Governor, state legislation, city position (mayor, council, local board) 
● Both federal and state/local 
● I’m not sure 

Where did this happen? 

● Location name 
[Generic] Examples: Name of business, school, intersection, prison, polling place, website, etc.   
● Street address 1 (​optional) 
● Street address 2 (​optional) 
● City/town 
● State  

Example of visual styling 

[If the user flags their primary concern as Special Litigation or Criminal Section-related] 

Location details 

Example of visual styling 

Please tell us the city, state, and name of the location where this incident took place. This ensures your concern is 
reviewed by the right people within the Civil Rights Division.​ ​Learn more about our privacy policy. 

Did this happen while in custody or incarcerated? 
● Yes 
○ What type of prison or correctional facility? 
■ State/local 
■ Federal 
■ Private 
■ I’m not sure 
● No 

Please include the inmate number if you know it 
Prisons and correctional facilities assign each person with an inmate number, which is usually required for contacting a 
prisoner.  
● Inmate number (optional) 

Where did this happen? 

● Location name 
[Generic] Examples: Name of business, school, intersection, prison, polling place, website, etc.   
● Street address 1 (​optional) 

● Street address 2 (​optional) 
● City/town 
● State  

[If the user flags their primary concern as occurring in a commercial or public place] 

Location details 

Example of visual styling 

Please tell us the city, state, and name of the location where this incident took place. This ensures your concern is 
reviewed by the right people within the Civil Rights Division.​ ​Learn more about our privacy policy. 

Please choose the type of location that best describes where the incident happened 
● Place of worship (or related to its construction) 
Church, synagogue, temple, or religious community center  
○ Was this incident related to permits or zoning? 
■ Yes 
■ No 
● Healthcare facility 
An inpatient or outpatient hospital or clinic, reproductive care clinic, state developmental institution, or nursing 
home 
○ Was the facility a reproductive care clinic? 
■ Yes 
■ No 
● Commercial or retail building 
Store, restaurant, bar, hotel, or theater 
● Financial institution 
Bank, credit union, or loan services  
● Public space 
Park, sidewalk, street, or other public buildings like a courthouse, DMV, or city library 
● Online 
Website, software, or mobile application 

● Other (please describe) 
○ [optional - text box] 

Where did this happen? 

● Location name 
[Generic] Examples: Name of business, school, intersection, prison, polling place, website, etc.   
● Street address 1 (​optional) 

● Street address 2 (​optional) 
● City/town 
● State  

Personal characteristics 
Do you believe any of these personal characteristics influenced why you were 
treated this way? 

Example of visual styling 

There are federal and state laws that protect people from discrimination based on their personal characteristics. Here is a 
list of the most common characteristics that are legally protected. Select any that apply to your incident.   

● Age 
● Disability (including temporary ​or recovery​)Family, marital, or parental status 
● Gender identity (including gender stereotypes)  
● Genetic information (including family medical history) 
● Immigration/citizenship status (choosing this will not share your status) 
● Language 
● National origin (including ancestry and ethnicity) 
● Pregnancy 
● Race/color 
● Religion 
● Sex  
● Sexual orientation 
● None of these apply to me 
● Other reason 

[if other is selected] 
● Please describe ‘Other reason’ 

Personal description 
In your own words, describe what happened 

Please share details like:  
● Time;  
● Names of people involved including witnesses if there are any; and 
● Any supporting materials (please list and describe them).   

Example of visual styling 

Previous reports 
Have you submitted this concern before?  

Knowing if you’ve submitted the same or similar concern before could help us find the original reviewer or collaborate 
with other agencies 

Have you submitted this concern to the Civil Rights Division of the Department of Justice before? 
● Yes 
○ Please provide details on when and how you filed previously: 
● No 

Have you submitted this concern to any other local, state, or federal agency? 
● Yes 
○ Please describe the agency and when you submitted it:  
● No