[DC GOVERNMENT] Employment_Intake_Questionnaire

Section 1 of 4 in this document

Employment Intake Questionnaire Form

Preferred Name *

Preferred Pronouns

Full Address

Street Address *

City *

State *

Zip *

Telephone *

Telephone (W)

Personal Email Address

Work Email Address (Optional)

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:

Full Address

Street Address

City

State

Zip

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

Name of company or organization *

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

Full Address

Street Address *

City *

State *

Zip *

Telephone (H) *

Fax

3. Basis of Complaint

Do you feel you were discriminated against because of your:

Race

Political Affiliation

Sexual Orientation

Sex

Disability

Marital Status

Age

Genetic Information

Matriculation

Family Responsibilities

Gender Identity or expression

Color

National origin

Religion

Personal Appearance

Retaliation

Status as a Victim/Family Member of Victim of Domestic Violence, Sexual Offense, or Stalking (DVSOS)

Credit Information

Homeless Status

Section 2 of 4 in this document

4. Jurisdiction

Please check all that apply:

Alleged violation occurred in the District of Columbia.

For Non-DC government employees: Alleged violation occurred one year or less - from today’s date.

For DC government employees: Alleged violation occurred within 180 days or less from the date you reported to a certified agency assigned EEO Counselor. *NOTE: DC Government employees can report claims of sexual harassment or DC FMLA directly to Office of Human Rights within one year of incident.

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

5. Issues

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

Promotion

Hostile Work Environment

Retaliation

Family Medical Leave

Failure to Hire

Sexual Harassment

Discipline

Transfer

Demotion

Discharge

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

Disclosure (DVSOS only)

Other

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.

Yes

Counselor's Agency

Counselor's Name

Counselor's Telephone Number

Date You First Contacted the EEO Counselor

Date of Exit Letter

If you have received an Exit Letter, please upload.

Click Here to 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?

Yes

Section 3 of 4 in this document

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

Full Name

First Name

Last Name

Phone Number

Witness Two

Full Name

First Name

Last Name

Phone Number

Witness Three

Full Name

First Name

Last Name

Phone Number

9. YOUR COMPLAINT:

Please provide a detailed statement of the incident that led to file a complaint of discrimination. Please include relevant dates, the name(s) of the person(s) who discriminated against you, and how the bases and issues you indicated above are connected. If this information is not included, your complaint may be dismissed. *

10. REFERRAL INFORMATION

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

Family, Friend or Acquaintance

OHR Social Media (Facebook, Twitter, etc.)

Event or Training

News Story (print, radio, TV or web)

EEO Counselor

DC Government or 311 Phone Number

OHR Advertisement

OHR Employment Rights Sign in Workplace

OHR Website or Search Engine

OHR Brochure or Flyer

Equal Employment Opportunity Commission

Community Organization or Non-Profit (Please enter name in box below)

Lawyer or Legal Aid Clinic (Please enter name in box below)

Other (Please enter referral source below)

Additional Referral Information:

Email Address

Please Acknowledge below

I want to file a charge of discrimination and/or retaliation, and I authorize OHR to investigate the allegations described above.

Please Acknowledge below

I understand that OHR must inform the target of my complaint of the allegations described above and information about the charge, including my name.

Please Acknowledge below

I acknowledge that OHR may investigate additional claims under other applicable laws.

Please Acknowledge below

I agree to cooperate with OHR’s processes and to treat OHR’s employees in a respectful manner. I understand that failure to do so may lead to dismissal of my complaint.

Please Sign

First Name

Last Name

Choose how to sign

Draw Type

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.

Recaptcha Response

Be sure to verify that you are not a robot by using the Captcha tool at the below.

Having reCaptcha issues? Click here to reset the widget.

disregard this