Equal Opportunity Intake Questionnaire (New)

Hillsborough County Equal Opportunity Administrator's Office Intake Questionnaire

Your Name*

First Name

Middle Name (optional)

Last Name

Your Address*

Address Line 1

Address Line 2

City

State

ZIP Code

I have a*

Home phone Work phone Mobile phone Check All

Home Phone*

Include area code - do not add dashes or parentheses

Work Phone*

Include area code - do not add dashes or parentheses

Mobile Phone*

Include area code - do not add dashes or parentheses

Best telephone number to contact you*

Home Work Mobile

Your Email Address*

Type of Harm

Was the harm or action taken against you in*

Employment Housing Public Accomodations Hillsborough County Contracting and Procurement Credit Extension Practices

Other:

Employment Claim

I believe I was discriminated against by the following organization(s)*

Employer Union Employment agency

Other:

Check all that apply

Does the organization employ 5 or more full time employees*

Yes No Not sure

Include all location/branches/offices

This is for

Current job (still employed) Past job Job I applied for

Date Hired

Job Title at Hire

Job Title at Discrimination

Date Quit/Discharged

Name and Title of Immediate Supervisor

Date Applied for Job

Job Title Applied for

Housing Claim

I believe I was discriminated against by the following person/entity*

Owner Builder Sales Person/Realtor Manager Bank or Other Lender

Other:

What type of property was involved*

Single Family House A house or building for 2,3,4 families A building for 5 families or more

Other:

Claim Details

Last date discrimination and/or harrassment occurred*

The date of the most recent alleged discrimination and/or harassment incident

Respondent(s) Information

This is the person or people you believe to be responsible for the alleged discrimination and/or harassment.

How many respondents*

1 2 3 4 or more

Respondent's Name*

First Name

Middle Name (optional)

Last Name

Respondent's Organization (if applicable)

Respondent's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Do you have the respondents*

Work phone number Personal phone number Neither work or personal phone numbers

Respondent's Work Phone*

Include area code - do not add dashes or parentheses

Repondent's Personal Phone*

Address of the property where the alleged harm or action took place*

Address Line 1

Address Line 2

City

State

ZIP Code

Respondent #2

Respondent #2 Name*

First Name

Middle Name (optional)

Last Name

Respondent #2 Organization (if applicable)

Respondent's #2 Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Do you have respondent #2*

Work phone number Personal phone number Neither work or personal phone numbers

Respondent #2 Work Phone*

Include area code - do not add dashes or parentheses

Respondent #2 Personal Phone*

Respondent #3

Respondent #3 Name*

First Name

Middle Name (optional)

Last Name

Respondent #3 Organization (if applicable)

Respondent's #3 Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Do you have respondent #3*

Work phone number Personal phone number Neither work or personal phone numbers

Respondent #3 Work Phone*

Include area code - do not add dashes or parentheses

Respondent #3 Personal Phone*

4 or More Respondents

Upload a single document with the following information for each additional respondent:

Respondent's first and last name (middle name if available)
Respondent's organization (if applicable)
Respondent's address
All available phone numbers for the respondent (indicate if the number is a work or personal number)

Additional Respondents Information*

No File Chosen

File uploads may not work on some mobile devices.

Claim Description

What happened to you that you believe was discriminatory? Include the date(s) of harm, the action(s), and the name(s) and title(s) of the person(s) you believe discriminated against you.*

Describe in detail how you were treated differently because of your actual or perceived race, color, sex, age, national origin, religion, disability, marital status, familial status, sexual orientation, or gender identity or expression; or how you were retaliated against or sexually harassed.*

Do you believe you were treated differently from people outside your protected class? *

Yes No

Provide the race, color, national origin, sex, disability, familial status or, the religion of these individuals, if known, and if it relates to your claim of discrimination*

Do you have a disability, which is a physical or mental impairment that substantially limits a major life activity, such as caring for yourself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, or working?*

Yes, I have a disability I do not have a disability now, but I did have one No disability, but the organization treats me as if I am disabled No disability, but the organization is aware that I am caring for a disabled individual No disability and none of the above

Witnesses

How many witnesses can you provide information about?*

None 1 2 3 4 or more

These are people who have firsthand knowledge regarding the incidents you have described in this complaint

Witness #1

Witness #1 Name*

First Name

Last Name

Witness #1 Phone Number*

Include area code - do not add dashes or parentheses

Witness #1 Relationship to Complainant*

Enter None if you do not have a relationship with this witness

What does witness #1 know?*

Witness #2

Witness #2 Name*

First Name

Last Name

Witness #2 Phone Number*

Include area code - do not add dashes or parentheses

Witness #2 Relationship to Complainant*

Enter None if you do not have a relationship with this witness

What does witness #2 know?*

Witness #3

Witness #3 Name*

First Name

Last Name

Witness #3 Phone Number*

Include area code - do not add dashes or parentheses

Witness #3 Relationship to Complainant*

Enter None if you do not have a relationship with this witness

What does witness #3 know?*

4 or More Witnesses

Upload a single document with the following information for each additional witness:

First and last name
Phone number
Relationship to the complainant (Enter None if you do not have a relationship with the witness)
Describe what the witness knows

Additional Witness Information*

No File Chosen

File uploads may not work on some mobile devices.

Investigation and Help History

Has this allegation been filed anywhere else?*

Yes No

For example, EEOC, Florida Commission on Human Relations, HUD, etc.

Name of Agency*

Contact Person at the Agency*

First Name

Last Name

Telephone number*

Date of filing*

Have you sought help about this situation from a union, an attorney or any other source?*

Yes No

Name of organization*

Name of the person you spoke with*

First Name

Last Name

Date of contact*

Results or outcome, if any*

Remedy Sought

What remedy or relief are you seeking?*

Declaration

RIGHTS AND RESPONSIBILITIES

Please read the following information carefully and sign your name in the designated space below.

The Hillsborough County Equal Opportunity Administrator’s Office is a county agency that investigates complaints of discrimination. We are a NEUTRAL AGENCY and our job is to investigate the allegations contained in your complaint.
The investigator assigned to your complaint is not your attorney. He or she is a neutral party dedicated to finding the facts in your complaint and making recommendations.
The investigator will interview witnesses on your behalf. It is your responsibility to provide the investigator with a method of contacting those witnesses (names, addresses, etc.)
Both parties may agree to participate in a voluntary mediation in an effort to resolve the charge(s) filed.
It is not necessary that an attorney represent you while we handle your complaint. However, you have the right to have an attorney, if you so desire. If an attorney represents you, we ask that you tell the attorney to write the Equal Opportunity Administrator’s Office confirming that he or she does represent you.
It is your responsibility to: 1) accept and respond to mail sent to you; 2) maintain contact with this office; and 3) notify your investigator of any change in your address or telephone number.
Remember, the investigation of your complaint will focus on whether there is reasonable cause to believe you were unlawfully discriminated against because of your race, color, sex, age, national origin, religion, disability, marital status, familial status, and sexual orientation, or gender identity or expression. (Familial status discrimination applies to housing discrimination complaints only.)

I declare that I have read this complaint and that it is true and correct and by signing below I also acknowledge and understand my rights and responsibilities.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Date/Time*