Incident Date
*
January
February
March
April
May
June
July
August
September
October
November
December
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2013
2012
Incident Time
*
01
02
03
04
05
06
07
08
09
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Mode
*
<select one>
Bus
Rail
Hudson Bergen Light Rail
RiverLINE Light Rail
Newark Light Rail
Website
MyTix
Access Link
First Name
*
Middle
Last Name
*
Address
*
City
*
State
*
Zip
*
Phone
*
Alternate Phone
Email
*
Verify Email
*
Person(s) discriminated against (if someone other than complainant)
First Name
Middle
Last Name
Address
City
State
Zip
Which of the following best describes the basis of the alleged discrimination
Affectional orientation
Age
Ancestry
Atypical hereditary trait
Civil Union
Color
Creed
Disability
Domestic Partnership Status
Familial status
Gender expression
Gender identity
Genetic status
Limited English Proficiency (LEP)
Marital status
National origin
Not Applicable
Race
Religion
Sex
Sexual orientation
Veteran / Military status
Retaliation
Description of the alleged discrimination incident. Please provide as much detail as possible, including names and titles (if known) of any NJ TRANSIT employees involved. Explain what happened, to whom, and who you believe was responsible.
By checking this box, I certify that the information on this form is true and accurate to the best of my knowledge.