HIV - Related Discrimination Complaint Report

This Complaint Report provides the entry into the National HIV-related Discrimination Reporting and Redress System. It can be completed by, or on behalf of, anyone who believes he/she has experienced or witnessed HIV-related mistreatment, abuse or discrimination, regardless of his/her HIV status. Once submitted, this information will be handled in a secure, confidential manner by trained officers. Statistical information may be shared with national or regional monitoring agencies, but personal or identifying information will be kept strictly confidential. Completion of this form indicates your agreement with these conditions.
When completed, this form should be submitted by fax or post to:
NHDRRS Officer, Jamaican Network of Seropositives
3 Trevennion Park Road, Kingston 5 | Phone/fax: (876) 929-7340

Required Fields! (*)
	1.	Today's date: Month: Day: Year:
*	2.	Name, nickname or alias of person experiencing discrimination (if known and permission is granted).
		Name, Nickname or Alias: Signature:
*	3.	Contact information of person experiencing discrimination:
		Mobile phone: Home phone: Email address:
*	4.	Age of person experiencing discrimination:
		<15 15-19 20-24 25-29 30-34 35-39 40-44 45 and Over
*	5.	Gender of person experiencing discrimination:
		Male Female Transgender Other
*	6.	Are you submitting this report for another person? Yes No
If yes, did you witness the incident? Yes No   If you are submitting this report for another person, please provide your name and contact information:   Name: Agency: Signature:   Mobile phone: Work phone: Email address:
*	7.	Has the incident been previously reported?
		Unsure No Yes
*	8.	Please provide information about the alleged offender (if known):
		Name: Title: Agency:
		Contact Number: Badge or identification number:
*	9.	Nature of the incident (check all that apply):
		Not Hired Physical violence Breach of confidentiality Forced to leave job Forced to leave school Harassment/Verbal abuse Not accepted into school Denied access to healthcare Denied housing Discrimination against relative Forced to leave home/community Other (please specify):
*	10.	Setting where first incident of discrimination occurred (check one):
		School Church Home Community Workplace Private Company/Business Private health facility Government health facility Law Enforcement Site Government Agency Other (please describe):
	11.	Pleae provide a short description of the incident:
*	12.	What further action, beyond documenting this incident, does the person experiencing discrimination want?
		No additional action Referral for counselling or social assistance
		Sensitisation session with alleged offender and/or community Legal or other redress
(Detach here)
		Thank you for your report. It was completed on: by:
		If you do not receive a response within 30 days, please call 929-7340 and ask to speak to an interviewer.