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DISTRICT OF COLUMBIA GOVERNMENT

OFFICE OF HUMAN RIGHTS

PUBLIC ACCOMODATION INTAKE QUESTIONNAIRE

COMPLETING THIS INTAKE QUESTIONNAIRE DOES NOT CONSTITUTE THE FILING OF A DISCRIMINATION CHARGE.

Disclaimer: Information required therein will assist the DC Office of Human Rights (OHR) to determine whether the allegations of discrimination are sufficient to the filing of a complaint, as defined by the D.C. Human Rights Act of 1977, as amended, Title VII of the Civil Rights Act of 1964, Title I of the American with Disabilities Act of 1990 (ADA) and the Age Discrimination in Employment Act (ADEA), among other laws and regulations. Please complete the following form in its entirety and to the best of your knowledge. This form is subject to review and acceptance by the OHR.

Notice of Non−Discrimination

In accordance with the DC Human Rights Act of 1977, as amended, DC Official Code Section §§2−1401.01 et seq. ,(Act) the District of Columbia does not discriminate on the basis of actual or perceived: race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, gender identity or expression, familial status, family responsibilities, matriculation, political affiliation, genetic information, disability, source of income, victim of an intrafamily offense, or place of residence or business. Sexual harassment is a form of sex discrimination which is prohibited by the Act. In addition, harassment based on any of the above protected categories is prohibited by the Act. Discrimination in violation of the Act will not be tolerated. Violators will be subject to disciplinary action.

*Required Fields

1. COMPLAINANT INFORMATION

*Date:

*Name:

*Address:

*City/State/Zip:

*Phone Number(Home):

*Phone Number(work):

*Race:

*Sex:

*Social Security No::

*Primary language spoken in your household:

VIetnamese

Korean

Spanish

*Date of Birth:

Amharic

Chinese

Other

*Email Address::

Contact person if you cannot be reached :

*Name:

*Street Address:

*City/State/Zip:

*Phone Number(Home):

* Phone Number(Work):

If represented by counsel, please provide the following:

Name:

Phone/Fax:

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

*Name of company or organization:

*Name and title of principle officer(i.e. President, Owner, Human Resources Manager):

*Nature of business:

*Address::

*City:

*State:

*Zip:

*Phone:

*Fax:

6. YOUR COMPLAINT

* Describe in detail the incident(s) that led you to file a complaint of discrimination. Please list dates as well as the name(s) of the person(s) who discriminated against you in denying employment, promotion, training, goods, services, educational services, etc. If this is a disability−based complaint, please specify whether an accommodation was requested; the person the request was submitted to and the date Respondent was notified of your disability.

The D.C. Office of Human Rights provides mediation. Mediation is a process in which an acceptable, impartial, third party attempts to assist disputing parties toward a mutual settlement. Two (2) mediators (co−mediators) are assigned to each case as a neutral third party to assist disputants in reaching a mutually acceptable resolution to their problem(s). The mediation process is mandatory and disputing parties design solutions to their own problems.

Please Note: In the event the Investigation reveals that your complaint should be dismissed you will receive a letter explaining the reasons for dismissal. Applicable regulations also require the OHR to send a copy of the dismissal notice to the Respondent.

SUBMITTING THIS INTAKE QUESTIONNAIRE DOES NOT CONSTITUTE THE FILING OF A CHARGE. The receipt of this complaint form by the Office of Human Rights will act as the filing date for statute of limitations purposes. But, the Charge of Discrimination is the formal document, on which the investigation and determination will be based.

Signature

*Date