[DC GOVERNMENT] Language Access Public Complaint Form

Language Access Public Complaint 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

Telephone (W)

How do you prefer we contact you?

Phone

Mail(using address provided)

What language do you prefer to communicate in?

Contact person if you can not be reached:

Contact Person's Primary Phone Number (NNN) NNN−NNNN:

Contact Person's Email Address

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

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

2. Respondent Information

If complaint is against an organization funded by the DC government, please list

Name of the D.C. government agency complained of:

Phone Number

If complaint is against an organization funded by the DC government, please list the name contact information for the organization here

3. COMPLAINT

Date of incident

Nature of Complaint:

Lack of assistance by agency staff in your language

Lack of translated materials

Other

If other, please describe

Did you alert agency staff of your language preference?

Yes

If yes, how?

Please describe in detail the nature of the problem with the agency/department/organization named above:

Please provide the name of the individual and/or organization that assisted you in completing

Contact Person/Position

Daytime Phone Number

Submitting this form does not constitute filing of charges The DC Office of Human Rights was established to eradicate discrimination, increase equal opportunity and protect human rights for persons who live, work, or visit the District of Columbia. The receipt of this complaint form by the Office of Human Rights will lead to an intake interview.

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.