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City of Alexandria, VA City of Alexandria, VA

Office of Human Rights

City Seal
Office of Human Rights
Intake Questionnaire Form

THIS IS NOT A FORMAL COMPLAINT: Your completion of this questionnaire does not signify that you have filed a formal complaint with the Alexandria Office of Human Rights. This questionnaire is for information only.

COMPLAINANT INFORMATION

Date Today:  enter date as mm/dd/yyyy   
Name:            DOB:       

Email:   
 
Address:   
 
City:               State:             Zip:     
Primary Phone No.:        Alternate Phone No.:      
Contact Person Name and Phone # (if you cannot be reached):    
 


I believe I have been discriminated against in the area of (check one):
 


I believe I have been discriminated against on the basis of my:  


When did the alleged discriminatory act occur? (Must be within 300 days if filing under Title VII, 180 days if filing under Age Discrimination in Employment Act, 365 days if filing under Housing)  


RESPONDENT INFORMATION
Name/Address of Company (Must be within City limits of Alexandria)  


President/Contact Person/Phone  

Date of Hire (Date of Hire (if applicable)
Position (if applicable)


Number of Employees (if applicable) RequiredFieldValidator ID="validateNumberEmployees" runat="server" ControlToValidate="radioemployees" ErrorMessage="Number of Employees is required">

Please list individuals involved (include full name and title):
1.

2.

3.

Please provide a brief description of the alleged discriminatory acts:   


The information you have provided herein is confidential. Respondents are not notified of this initial contact as this is not a formal complaint. This information will be forwarded to an investigator who will contact you promptly to schedule an intake interview at the office, to determine whether you have grounds for a formal complaint.

The City of Alexandria is committed to compliance with the American with Disabilities Act, as amended. To request a reasonable accomodation or an alternative format, e-mail mike.hatfield@alexandriava.gov or call 703.746.3148, Virginia Relay 711.