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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

Full Address

How do you prefer we contact you?

ARE REPRESENTED BY COUNSEL, PLEASE PROVIDE THE FOLLOWING:

Full Address

2. RESPONDENT

Full Address

3. BASIS OF COMPLAINT

Do you feel you were discriminated against because of your: (Please check appropriate box)

4. JURISDICTION

All fields must be checked

5. Issue of Complaint

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

Date of alleged incident:

Person who denied your service request (If known)

Full Name

6. YOUR COMPLAINT

7. Referral Information

How did you hear about the DC Office of Human Rights (check all that apply)?

Please Sign to Confirm Submission

Sign Here

Choose how to sign

Full Date

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