an initiative of the Sikh Coalition
CONTACT INFORMATION
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Are you completing this form on behalf of another individual?
No
Yes
Individual Information
Full Name
*
Email Address
*
Phone Number
Address
*
City
*
State
*
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
INCIDENT REPORT
On what ground(s) do you believe you experienced discrimination?
Race/Ethnicity
Religion
National Origin
Gender
Disability
Other
Please describe what discrimination you experienced
Which U.S. airport were you traveling through?
*
What was the date and approximate time of the incident?
*
Date
*
HH
*
MM
*
AM/PM
*
AM
PM
What was the airline and flight number?
*
At the security checkpoint, which screening types did you undergo?
*
Metal Detector
Body Scanner
Other
If you walked through a metal detector, did TSA personnel require you to go through additional screening after you went through the metal detector?
No
Yes
If you walked through a metal detector and were required to go through additional screening, did you go through such screening because the metal detector went off or sounded?
No
Yes
If you walked through a metal detector and were you required to go through additional screening, what type of additional screening did you go through?
Handheld Metal Detector
Explosive Trace Detection (hand swab)
Officer Patted Down
Self-pat down
Private Screening
None of the above
Please describe what screening did you had to go through:
*
Please describe what screening you had to go through:
*
If you walked through a Body Scanner, did TSA personnel require you to go through additional screening after you walked through the machine?
No
Yes
What type of additional screening did you go through?
Handheld Metal Detector
Explosive Trace Detection (hand swab)
Officer Patted Down
Self-pat down
Private Screening
None of the above
Please describe what screening you had to go through:
*
If known, please enter the name(s) and badge number(s) of the TSA officer(s) who screened you
Were there any witnesses who may have seen / heard what happened?
No
Yes
Have you contacted the TSA Customer Service Manager at the airport, or any other DHS component or other federal, state, or local government agency or court about this complaint?
No
Yes
Has anyone responded back?
No
Yes
