ILLINOIS GENDER ADVOCATES
Public Advocacy for the Transgender and Gender Variant Community
Discrimination and Violence Project

Instructions:  Please print or save to a word processor file. Please fill out as much of the requested information as possible, including as much detail as you wish.  Much of the requested information is optional.  Information from your case will be abstracted and reproduced in our reports on discrimination against transgender and gender variant people .  If you need more space than provided, use additional pages. All personal details will be omitted from these reports.  However, we do require at the very least your name and some means to contact you.  Please print legibly or type.
 

Name:_______________________________________________________________

Street Address:________________________________________________________

City:_____________________

State:_____  Zip Code:______________   County:_____________________

E-mail address:_________________________________________________

Telephone Number:(_______)  _________-_______________

Gender Identity :

   Trangender ____ Transsexual ____ Cross-dresser____ Gender Queer ____

    Drag (Queen or King) ____ MtF ____ FtM ____ Butch Lesbian ____ 

    Other (please describe) _______________________________________

Age (optional):_______ Are you a youth (up to age 22)? ___________

Sexual Orientation (optional) ________________________________

Date discrimination took place (Month, Day, Year or Continuing if it is still taking place)
 

__________________________________

Type of Discrimination (Check as many as apply):

 __Employment __Housing __Public Accomodations
 __Credit Transaction __Contracts __Public Facilities, Services or Programs
 __Sexual Harassment __Hate Crime __Civil Rights __ Domestic Violence
 __Other (please describe) : _______________________________________________________

1.  Please tell us about your case.  Summarize your case in as much detail as needed. Take as much space as you need. If additional space is needed, attach extra sheets.  Be sure to answer the basic questions: what happened, when did it happen, who was involved, and where did the incident occur.
 
 
 
 
 
 
 

2.  Describe the circumstances leading up to your case.  For example, had you just begun transition,  or were you discovered or "outed" by co-workers?  Did the others who discriminated against you know that you were transgendered, and how did they know?
 
 
 
 
 
  
 

3.  If this is employment discrimination, describe the type of business, what you did there, how long you were employed there, and your personnel record prior to the incident.
 
 
 
  
 
 
  

4.   What was the outcome of the incident.  For example, were you fired or denied promotion?  Were you harassed, or subjected to physical abuse?  Was your family affected?   Did you suffer financial hardships as a result?
 
 
  
 
 
 
  

5.  Was the incident reported to any authorities (such as police or human relations commission,).  What was their response to your case?   Are you now or have you been involved in a lawsuit over the incident?  Are there others who can back up your account?  Provide as much detail as possible.  Names will not be used in the report.
 
 
 
 
  
 
  

6.  Provide as many other details as you need to tell your story.  Use continuation pages if necessary. 
 
 
 
 
 
 
 
  

I declare that the foregoing is true and correct.  Furthermore, I hereby authorize Illinois Gender Advocates to
include my case in their report.

 

Signature:                                                         Date:


   Mail completed form to:
   IGA Documentation Project
   47 W. Division Street, #391
   Chicago, IL 60610

   Or e-mail to IGA@genderadvocates.org