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NAACP Discrimination Report Form
The NAACP wants to learn about possible civil rights violations during the coronavirus pandemic. Please tell us about your experience using the form below.
Contact Information
Name
*
First Name
*
Last Name
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Email
*
Phone
*
Demographics
Gender
*
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:
Other Value
Check all that apply
Is this an individual or group issue or concern?
*
Individual
Group
Which group?
*
Please explain the issues/concerns that you selected above.
*
Characters remaining:
1000/1000
What actions have you taken to address the issues or concerns (persons contacted, resources used, etc.)
*
Characters remaining:
1000/1000
Is your issue or concern tied to a specific company or organization?
*
Yes
No
Company/Organization Name
*
Company/Organization City
*
Company/Organization State
*
Date/Time
*
https://naacpforms.formstack.com/forms/images/2/calendar.png
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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26
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28
29
30
31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Hour
01
02
03
04
05
06
07
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09
10
11
12
Minute
:
00
01
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AM/PM
AM
PM
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