File a Complaint Under the Americans with Disabilities Act against the County

Department Resources

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:

Mobile 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 Government policy, only the person harmed or their legal guardian can file with the OHREP.)

Yourself

Someone Else

If the person discriminated against is 18 or older, we will need that person’s signature before we can proceed with this complaint. Under Fairfax County government policy, only the person harmed or their legal guardian can file with OHREP.

If someone other than yourself, please include:

Injured person’s name:

Relationship to you:

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

3. Enter information about the department and/or person(s) who discriminated against you.

Agency Name:

Address:

City:

State:

Zip:

Primary Phone:

Alternate Phone:

Name of Person(s) who discriminated against you:

1. Name:

Position/title:

2. Name:

Position/title:

3. Name:

Position/title:

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

a. Date (s) the discriminatory action occurred;
b. Name(s) of individual(s) who discriminated (include position, title);
c. Location of alleged violation;
d. What happened;
e. Witnesses, (if any);
f. Why you believe the discrimination was because of disability.

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

5. What solution are you seeking?

Date Submitted:

Signature

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Human Rights and Equity Programs

Human Rights and Equity Programs Alert:

Department Resources

File a Complaint Under the Americans with Disabilities Act against the County

Fairfax Virtual Assistant

Human Rights and Equity Programs

Human Rights and Equity Programs Alert:

Department Resources

File a Complaint Under the Americans with Disabilities Act against the County

Details if submitting for someone else

Fairfax Virtual Assistant