[DC GOVERNMENT] Public Accommodations Form

Section 1 of 3 in this document

Public Accommodations 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

Preferred Pronouns

Telephone (W)

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:

Section 2 of 3 in this document

2. RESPONDENT INFORMATION

Name of Company or Organization

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

Phone Number

Fax Number

3. BASIS OF COMPLAINT

4. JURISDICTION

alleged violation occurred in the District of Columbia

Alleged violation occurred 365 days from today’s date

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

5. Issue of Complaint

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

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

Denial of Service

Other

If other, Please explain

Service you requested:

Person who denied your service request (If known)

Title

How is this person different from you (i.e. what is this person's protected basis?):

Have you tried to resolve this matter with Respondent? if so, please describe with whom you spoke and their response

6.Your Complaint

Please provide a statement of the key events, including relevant dates and how the bases and issues you indicated above are connected. If this information is not included your complaint may be dismissed

7. Referral Information

Additional Referral Information:

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First Name

Last Name

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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.

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Public Accommodations Form

How do you prefer we contact you?

ARE REPRESENTED BY COUNSEL, PLEASE PROVIDE THE FOLLOWING:

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

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

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

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Public Accommodations Form

Full Address

How do you prefer we contact you?

ARE REPRESENTED BY COUNSEL, PLEASE PROVIDE THE FOLLOWING:

Full Address

Full Address

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

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

Date of Alleged Incident:

Full Name

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

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