Please Read the Guidance Notes and the Notes on This Page Carefully Before Filling in This Form

Jersey Employment and Discrimination Tribunal

Application Form in respect of work related complaints of discrimination

Forms and explanatory leaflets available from the JEDT website:

Received at JEDT
Case No
Admitted

Please read the leaflet ‘Making a Claim’and the notes on page2carefully before completing this form.

You may find it helpful to take advice before completing this form.

This form concerns complaints of discrimination arising in connection with your work only.Please tick the box if your complaint is work related and complete this form.

If your complaint of discrimination is NOT concerned or connected with your work please complete form JDT1.

Please Note: A copy of this form will be sent to the other party/ies involved. We will also send a copy to the Jersey Advisory and Conciliation Service (JACS).

How to complete this form:

Please complete using CAPITAL letters and a black pen.

You must sign the form on page 8.

All applicantsmust completesections 1, 2 and 3. You then only need to complete those sections of the form that apply to your case.

For sums that you wish to claim, completesection 4.

Completesection 5 if you have a current complaint against your employer under the Employment (Jersey) Law 2003 and/or there is some other information you wish to draw to the Tribunal’s attention and section 6 only if you have appointed a representative to act on your behalf in dealing with your claim.

More than one section of this form may apply to your claim.

Please make sure that all the information you give is as accurate as possible.

Where there are choices i.e. Yes or No, pleasetickthe one that applies.

Please sign and date this form and return it to the Jersey Employment and Discrimination Tribunal. The Tribunal’s contact details are set out on page 9.

1. Your details
1.1Title: (please tick as appropriate) / Mr  Mrs  Miss  Ms Other 
1.2First name(or names):
1.3Surname or family name:
1.4Address: / Postcode:
You do not have to complete 1.5 or 1.6 if you have appointed a representative (see section 6)
1.5Phone number: (where we can contact you during normal working hours)
1.6E-mail address:
2. Respondent’s details
2.1Give the name of the Respondenti.e. theperson or organisation you arecomplaining about:
2.2Address: / Postcode:
2.3E-mail address & telephone
number:
2.4Is the person above also your employer?(tick yes or no) / YesNo
2.5 Do you also wish to make a complaint of discrimination against your employer? / YesNo
2.6If so supply details:
Name of your Employer:
Address of Employer: / Postcode:
Email address and telephone number:
2.7Did/do you work for the employer as an employee or contract worker? (delete as appropriate) / Employee/ Contract worker
3. Act of discrimination
3.1Was the alleged act of discrimination committed in Jersey?(tick as appropriate) / YesNo
3.2What was the date of the alleged act of discrimination to which this complaint relates: / Day / Month / Year
3.3Describe concisely the alleged act/s of discrimination that you wish to complain about:
3.3 Continued
If there is not enough space, please continue on a separate sheet headed section 3.3 and attach it to this form.
Number of sheets attached ……….
4. Remedies sought
4.1Do you wish to make a claim for compensation for:
4.1.1 Financial loss (please tick as appropriate): YesNo
If yes, provide details of the amount of money that you believe is owed to you and how it arises:
4.1.2Hurt and Distress (please tick as appropriate): YesNo
If yes, describe concisely the type of hurt and distress which you believe has resulted from the act/s:
If there is not enough space, please continue on a separate sheet headed section 4.1.1 or 4.1.2 (as appropriate) and attach it to this form.
Number of sheets attached……..
5. Other information
5.1 Do you also have a current complaint against your employer under the Employment (Jersey) Law 2003? (tick as appropriate)YesNo
If yes, provide the case reference number if known ……………………
5.2 You may add any extra information here about your discrimination complaint that you want us to know:
If there is not enough space, please continue on a separate sheet headed section 5.2 and attach it to this form.
Number of sheets attached ……….
6. Your representative

Please complete this section only if you have appointed a representative. If you do fill this section in, we will in future only send correspondence to your representative and not to you. It is your representative’s duty to keep you informed.

6.1Representative’s name:
6.2Name of the representative’s organisation (if applicable):
6.3Address: / Postcode:
6.4Phone number:
6.5E-mail address:
6.6Reference number assigned by representative to this case (if known):
7. Please date and sign here. You must complete the checklist overleaf
Date: / Signature:

Data Protection (Jersey) Law 2005.

All information provided is treated in compliance with the Data Protection (Jersey) Law 2005. The information is required by the Tribunal to assess the claim. A copy of this form will be sent to the other party/parties. A copy of this form will also be sent to JACS.

Please check the form to ensure that you have included all the relevant information.

Application Form JEDT 1- Check list

Have you listed the following?

Tick √ the boxes below to ensure you have included the information required for initial acceptance.

Your FULL name and contact numbers
Your FULL postal address, including postcode
The first Respondent’s name in full
The first Respondent’s address
The second Respondent’s name in full
The second Respondent’s address
Your representative’s name in full and contact details (if applicable)

Please forward the completed form to: The Registrar

Either by post

or personal delivery to:

Jersey Employment and Discrimination Tribunal

1st Floor

Trinity House

Bath Street

St Helier

JE2 4ST

Or by e-mail to:

Or by fax to:(01534) 625898

For general enquiries please telephone (01534) 441380. There is no fee payable upon lodging this form. The office is open to the public between 9.30 am and 4.00 pm each day.

JEDT1

2014