[DC GOVERNMENT] Language Access Complaint Questionnaire_Updated_4.15.2025

Date/Update: March 3, 2025

This form is subject to review by the Language Access Director to determine the jurisdictional requirements have been met and acceptance by OHR. Fields marked with an asterisk (*) to the left are required fields and must be completed.

Section 1: Jurisdiction (Please Check All That Apply)

Check all that applies

Alleged violation occurred in the District of Columbia

Alleged violation occurred within one year of the filing of the intake questionnaire

Alleged violation is being filed against a D.C. government agency, department, program, or its funded entity

Section 2: Complainant Information

What Are Your Pronouns?

he/him

she/her

they/them

Other

Other, Please specify

Address

Street Address

City

State

Zip

How do you prefer we contact you?

Phone

Mail

Do you need a reasonable accommodation?

Yes

Other

What language do you prefer to communicate in?

English

Amharic

Chinese

French

Korean

Spanish

Vietnamese

Other

Do you require a language interpreter?

Yes

Do you require a language interpreter?

Alternative contact person email address

Alternative contact person phone number

Section 3: Attorney or Counsel Information (Optional)

Counsel Address

Street Address

City

State

Zip

Counsel Telephone Number

Counsel Email Address

Section 4: Respondent Information

Name of D.C. government agency/department/program/funded entity

Address of D.C. government agency/department/program/funded entity:

Street Address

City

State

Zip

Name of the person from the D.C. government agency/department/program/funded entity who assisted you

Phone Number of D.C. government agency/department/program/funded entity

Email Address of person from the D.C. government agency/department/program/funded entity who assisted you

Section 5: Complaint

Nature of Complaint

Lack of oral interpretation services

Lack of translation of written materials

Other

Have you informed the staff of the D.C. government agency, department, program, or funded entity of yourlanguage preference to communicate?

Yes

Other

Other, Please explain

Did you ask the D.C. government agency, department, program, or funded entity that you contactedto provide you with translated documents?

Yes

If yes, what documents did you request?

Were these documents available in your language?

Yes

Have you tried to resolve this issue with the D.C. government agency, department, program, orfunded entity?

Yes

Date on which you tried to resolve the issue with the D.C. government agency or funded entity

Name of the person you spoke with at the D.C. government agency or funded entity

First Name

Last Name

The D.C. government agency or funded entity response

Please provide a detailed statement of the incident that led to filing a language access complaint.If this information is not included, your complaint may be dismissed.

Please indicate the name of the person and/or organization that helped you complete this form (if applicable)

First Name

Last Name

Primary telephone number of the person that helped you complete this form

Email address of the person that helped you complete this form

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First Name

Last Name

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Language Access Initial Written Complaint Questionnaire (English)

Section 1: Jurisdiction (Please Check All That Apply)

Section 2: Complainant Information

Section 3: Attorney or Counsel Information (Optional)

Section 4: Respondent Information

Section 5: Complaint