Discrimination Complaint Questionaire - Public Accomodations


Please be advised that by completing this form and returning it, you have not filed a formal complaint as required under the Fairfax County Human Rights Ordinance. Upon receipt of your completed form, commission staff will review your form and contact you to finalize the process.

1. Enter information about yourself.


First Name:*     Last Name:*  

Address:  

City:    State:    ZIP:  

Best time to call you:  

Home Phone:*    Cell Phone:    Work Phone:  

E-mail address:*  


Who else can we contact if we cannot reach you?

Contact's name:    Contact's phone:  

Relationship to you:  

 

2. Who was discriminated against?  (Under Fairfax County Human Rights Ordinance only the person harmed or their legal guardian can file with the HRC.) 

Yourself
Someone else

If the person discriminated against is age 18 or older, we will need that person's signature before we can proceed with this complaint. Under the Fairfax County Human Rights Ordinance only the person harmed or their legal guardian can file with the Human Rights Commission. 

If someone other than yourself, please include:

Injured person's name:  

Relationship to you:  

Address:    County:  

City:    State:    ZIP:  

Daytime phone:    Evening Phone:  

 

3. Name of the business that discriminated against you?


Business Name:  

Address:    County: Fairfax County

City:    State:    ZIP:  

Primary phone:    Alternate Phone:  


Name of Person(s) who discriminated against you:

1.    Position/title:  

2.    Position/title:  

3.    Position/title:  


I believe I have been discriminated against because of my: (check one or more)

Race     Religion      Disability     Color     Sex     Age (Date of birth: mm/dd/yyyy)

National Origin    Marital Status    Other   

4. In the space provided below, please briefly describe each discriminatory action seperately. For each action, you need to provide the following information:

a. Date(s) the discriminatory action occurred;

b. Name(s) of individuals(s) who discriminated (include position, title);

c. What happened;

d. Witnesses, (if any);

e. Why you believe the discrimination was because of [race, sex, disability, or whatever basis you indicated above] or why you believe the action was retaliatory.

 Do you have documents that you think will help us understand your complaint?
(If yes, you will be contacted with instructions for submitting this information. Do not send original documents.)

yes     no  

5. What solution are you seeking?

  
  

"Please be advised that by completing this form and returning it, you have not filed a formal complaint as required under the Fairfax County Human Rights Ordinance. Upon receipt of your completed form, commission staff will review your form and contact you to finalize the process."

 


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