Impact NW & YWCA Profiling Complaint Form

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This form is for use by Impact NW/YWCA employees who have either experienced profiling directly or wish to file on behalf of a community member who has experienced profiling.

We understand that it is often difficult to report on negative experiences. Thank you for your courage and willingness to make a difference.

Questions or Comments?

For help filling out this form or any questions or comments, please contact Impact NW's Equity and Diversity Committee at: divcomm@impactnw.org

Person Involved

Do you or the person involved wish to remain anonymous? If yes, leave the rest of this section (Person Involved) blank.

Note: Remaining anonymous may limit the action that can be taken on your behalf.

Yes

Name:

Phone or Email:

Are you the person involved?

Yes

Clear selection

Reporter's Information

(Skip this section if you are the person involved)

Name:

Phone or Email:

What is your relationship to the person involved?

Do you have permission to file a profiling complaint from the person involved?

Yes

Clear selection

Incident Information

All the questions below are optional, but please complete them to the best of your ability. Additional details are helpful, but not required.

Estimated Date or Date Range of Incident:

Note: If the incident occurred more than 120 days ago, still feel free to share your experience with us. However, the LECC will not be able to pursue action on the incident.

Location of Incident

Intersection, neighborhood, landmark, address

Where there any witnesses to the incident?

Yes

Clear selection

Describe the profiling incident:

In what ways did you feel you were treated unfairly?

Which identities were profiled?

Please check all that apply

Race / Ethnicity

Gender / Gender Identity

Houselessness / Housing Status

Sexual Orientation

National Origin

Age

Religion

Mental or Physical Disability

Political Affiliation

Other:

Would you like an Impact NW staff member to follow up with you regarding your incident?

Yes

Clear selection

Thank you for submitting your complaint.

This formal complaint will be submitted to the LECC (Law Enforcement Coordinating Committee). The LECC will forward the complaint to the agency involved within 30 days. This complaint may also be used to improve officer trainings and the annual report provided by the LECC. (If used in trainings or reports, identifying information will be removed.)

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