1. NAME & CONTACT INFORMATION

MCCR Complaint Preliminary Questionnaire (2026)

Please answer all questions as completely and accurately as possible. Fields marked with an asterisk (*) are required for completion. Incomplete or inaccurate information may result in a delay or termination of processing for this inquiry.

This Preliminary Questionnaire (PQ) takes approximately 20 minutes to complete, depending on how much detail you provide. The PQ may time out after prolonged inactivity, clearing out your entries. It is strongly recommended that you complete this on a computer.

	Complainant Personal Information (Person Filing Complaint)

Your Name:*
Please provide your legal name and your preferred name.

		Title		First		Middle		Last		Suffix		Preferred Name
Name

Street or Mailing Address

		Street		Unit		City		County		State		Zip
Address

Phone Number:*
Please enter at least 1 phone number at which you can be reached.

		XXX-XXX-XXXX
Home
Work
Cell

	Email Address:*

	Date of Birth:* mm/dd/yyyy

Sex:*

Ethnicity*

Hispanic or Latino

Not Hispanic or Latino

What is your race?*

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Other (Please Specify)

	What is your National Origin?* This is your country of origin or ancestry.

Do you have a disability?*

Yes

Prefer not to Answer

	Do you need an interpreter or a translator to use MCCR's services?

ASL Interpreter

Yes

If "yes", will you be requesting that MCCR provide you with an interpreter or will you be providing your own interpreter? If you are providing your own interpreter, please share their contact information (if available).

Translator

Yes

If "yes", will you be requesting that MCCR provide you with a translator or will you be providing your own translator? If you are providing your own translator, please share their contact information (if available).

	Please Provide The Name Of A Person We Can Contact If We Are Unable To Reach You. If MCCR is unable to reach you at any point during the intake and investigation processes, your complaint may be administratively closed.

	Name:

	Relationship:

Street or Mailing Address

		Street		Unit		City		County		State		Zip
Address

Phone Number:
Please enter at least 1 phone number at which you can be reached.

		XXX-XXX-XXXX
Home
Work
Cell

Have you sought help about this situation from an attorney, a union, or any other source?*

Yes

If yes, please provide the name of the organization, the name of person you spoke with, date(s) of contact, and results (if any).

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