Unemployed Anti-Discrimination Intake Questionnaire - Office Of Human Rights
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2Unemployed Anti-Discrimination Intake Questionnaire
Complaint Questionnaire
The District of Columbia Unemployed Anti-Discrimination Act prohibits employers, employment agencies or entities acting
on an employer’s behalf from discriminating against an individual applicant because they are unemployed. Individuals
who believe an employer, agency or entity failed or refused to consider them for employment, or failed to refuse or hire
them, because they were unemployed can file a complaint. More information about the law is available by visiting or call-
ing the Office of Human Rights or at ohr.dc.gov/page/unemployed.
Jurisdiction
To file a complaint, the alleged violation must meet the following criteria (please check the required boxes):
It occurred in the District of Columbia.
It occurred on or after the law’s effective date of October 1, 2015.
It occurred 365 days or less from alleged violation date.
Complainant Information
Incident Information
Complainant Preferred Name
Name of Company or Organization
Complainant Address
Name and Title of Principle Officer (i.e. owner or manager)
Complainant Telephone Number
Company or Organization Address
Complainant Email Address
Telephone Number
Do you need a reasonable accommodation?
Email Address of Principle Officer
Yes
No
If yes, please explain
Unemployed Status
If you are filing a complaint because you are alleging
What language do you prefer to communicate in?
discrimination based on unemployment status, please
English
Chinese
Korean
Vietnamese
ensure you meet the following three conditions (check
each box):
Amharic
French
Spanish
Other:
Unemployed at time of application/interview
Do you require a language interpreter?
Available to work at time of application/interview
Yes
No
Seeking employment at time of application/interview
If yes, which language?
If you are filing a complaint because you are alleging
Language indicated above
retaliation, please check the box below:
Other
I am alleging retaliation under the UADA.
Do you have a preferred gender pronoun (write below)?
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