[DC GOVERNMENT] Educational Institutions Questionnaire Form

Educational Institutions Questionnaire Form

Submitting this complaint questionnaire does not constitute the formal filing of a discrimination charge, but it serves to preserve all rights under the statute of limitations. The formal filing will take place when we review your questionnaire and hold an intake interview with you at the OHR Office.

1. Complainant Information

Preferred Name

Telephone

Preferred Pronouns

Telephone (W)

How do you prefer we contact you?

Phone

Mail(using address provided)

What language do you prefer to communicate in?

Do you require a reasonable accommodation? If so, please explain.

Do you require language interpretation? If so, what language?

ARE REPRESENTED BY COUNSEL, PLEASE PROVIDE THE FOLLOWING:

YES

Counsel Name

Telephone/Fax:

2. RESPONDENT

Name of Company or Organization

Name and Title of Principal Officer (i.e. President, Owner, Human Resources Manager):

Phone Number

Fax

3. BASIS OF COMPLAINT

4. JURISDICTION

All fields must be checked

You have not commenced any other action, civil, criminal, or administrative in any other forum based on the same unlawful discriminatory practice described herein.

Alleged violation occurred 365 days or less (6 months or less for D.C. Government Employees)

Alleged violation occurred in the District of Columbia.

5. Issue of Complaint

What action was taken that made you feel you were treated differently?

Terms and Conditions

Failure to Accommodate(i.e. Religion, Disability)

Admission or Admission Fees

Curriculum

Denial of Service

Program Participation

Other:

If Other, Please explain

Service you requested:

Person who denied your service request (If known)

Title

How is this person different from you (i.e. what is this person's protected basis?):

Have you tried to resolve this matter with Respondent? if so, please describe with whom you spoke and their response

6. YOUR COMPLAINT

Please provide a statement of the key events, including relevant dates and how the bases and issues you indicated above are connected. If this information is not included your complaint may be dismissed.

7. Referral Information

Additional Referral Information:

Please Sign to Confirm Submission

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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