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Employment Intake 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.

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Full Address

How do you prefer we contact you?

ARE REPRESENTED BY COUNSEL, PLEASE PROVIDE THE FOLLOWING:

Full Address

Please note: If you are represented by counsel or retain counsel prior to your scheduled Intake interview, the counsel must either (1) be present with you for the duration of your Intake interview, or (2) withdraw his/her appearance from the interview by submitting a letter to the Office indicating that the interview may take place without his/her representation

2. Respondent Information

Full Address

3. Basis of Complaint

Do you feel you were discriminated against because of your:

4. Jurisdiction

Please check all that apply:

5. Issues

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

6. DC Government Employees

Current, former, or prospective DC government employees must  first consult a certified agency assigned EEO Counselor within 180 days of the alleged discriminatory act prior to filing with the Office of Human Rights, unless the District Government employee is alleging unlawful discrimination based on sexual harassment or DC FMLA.

 

You have filed an informal complaint with an agency assigned EEO Officer/Counselor.

Date You First Contacted the EEO Counselor

Date Picker

Date of Exit Letter

Date Picker

If you have received an Exit Letter, please upload.

7. D.C. FAMILY AND MEDICAL LEAVE ACT (For FMLA complaint only)

If you have filed a Family and Medical Leave Act complaint, have you been employed with this company for at least one (1) year and have worked at least one thousand (1,000) hours?

8. WITNESSES:- List who can provide evidence in your support

Full Name

Witness Two

Full Name

Witness Three

Full Name

9. YOUR COMPLAINT:

10. REFERRAL INFORMATION

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

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