Discrimination Public Form

Mon, 05/28/2012 - 22:35 -- admin
SUBMITTING THIS INTAKE QUESTIONNAIRE DOES NOT CONSTITUTE THE FILING OF A CHARGE

General Information

Date of Initial Contact
Date of Initial Contact 27 Feb 2017

Your Details

Name
Last
First
Middle
Mailing Address
Number and Street
Apt#
City
State
Zip
Do you require reasonable accommodation?
Do you require reasonable accommodation?
Do you require language interpretation?
Do you require language interpretation?
Are you represented by counsel/attorney?
Are you represented by counsel/attorney?
Attorney/Counsel Name
Last
First
Middle
Attorney/Counsel Mailing Address
Number and Street
Apt#
City
State
Zip

Please note: If you are represented by counsel prior to your scheduled intake interview, the counsel must either 1) be present with your 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 th einterview may take place without his/her representation.

Voluntary Demographics

Sex
Sex

Respondent

Please add all respondents
Respondents
Name of OrganizationValidOptions

Nature of Discrimination

Do you feel you were discriminated against because of your
Do you feel you were discriminated against because of your
*Note: this is not currently a protected category under the laws of the City and County and will be used for tracking purposes only.

Jurisdiction

Please check all that apply
Please check all that apply

Your complaint

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that I am authorized to bind this entity contractually. *
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