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Is
there a contract number or procurement listing associated
with this incident?
Contract or Opportunity Reference Number:
When
did the incident occur?
Date or Range of Dates:
Describe
the acts of assistance providing the name(s) where possible
of the individual(s) involved:
Have
efforts been made to resolve any complaint through the internal
grievance procedure of the government, organization or institution?
Yes
No
If "yes" what was the effort?:
Has
this complaint been filed or do you intend to file with
another organization or agency or the Department of Justice
or any other Federal, State or local civil rights agency
or court?
Yes, I have filed
Yes, I intend to file
No, I have not filed and do not intend to file
If
"yes":
Is
there another agency or court you have filed or intend to
file with?
Yes, I have filed
Yes, I intend to file
No, I have not filed and do not intend to file
If
"yes":
Additional Comments:
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