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Philadelphia Commission on Human Relations
The Curtis Center
601 Walnut Street, Suite 300 South
Philadelphia, PA 19106-3304
Tel: 215-686-4670
E-mail: faqpchr@phila.gov
When completed, please fax this questionnaire to 215-686-4684.
DISCRIMINATION INTAKE QUESTIONNAIRE
Your Name ____________________________________________
Address ______________________________________________
Telephone Number (Day) ________________ (Night) __________
E-mail Address _________________________________________
Date of Birth ___________________________________________
Alternate Contact in an Emergency:
Name _________________________________________________
Address _______________________________________________
Telephone Number _______________________________________
Relationship ____________________________________________
AREA OF DISCRIMINATION:
(check applicable type)
Employment ___ Housing ___ Public Accommodations ___
City Services ___
NAME OF EMPLOYER/LANDLORD/BUSINESS OR CITY AGENCY THAT
DISCRIMINATED AGAINST YOU: ____________________________
______________________________________________________
ADDRESS ______________________________________________
TELEPHONE NUMBER _____________________________________
BASIS OF DISCRIMINATION (CHECK ALL THAT APPLY):
RACE__ COLOR__ RELIGION__ NATIONAL ORIGIN__
ANCESTRY__ SEX__ PREGNANCY__ SEXUAL HARASSMENT__
DISABILITY__ PERCEIVED DISABILITY__ SEXUAL ORIENTATION__
GENDER IDENTITY__ MARITAL STATUS__
AGE__ (DOES NOT APPLY TO PUBLIC ACCOMMODATIONS)
RETALIATION__(DOES NOT APPLY TO PUBLIC ACCOMMODATIONS)
ADDITIONAL BASES FOR HOUSING DISCRIMINATION:
SOURCE OF INCOME__ PRESENCE OF CHILDREN__
IF YOU ARE CLAIMING EMPLOYMENT DISCRIMINATION, ANSWER THE FOLLOWING QUESTIONS:
How many employees does the company have at all sites in total (approximate?)
What is the address for the corporate office if there is one?
____________________________________________________
____________________________________________________
What issue was involved?
__failure to hire __discipline __failure to promote __termination
__layoff __harassment __different treatment __difference in pay
__difference in benefits __difference in perks __other
IF YOU ARE CLAIMING HOUSING DISCRIMINATION, ANSWER THE FOLLOWING QUESTIONS:
What kind of situation was it?
__denial of rental unit __denial of sale __intimidation by neighbors
__steering by agent or broker __difference in rent __denial of mortgage
__difference in mortgage rates __harassment or inappropriate comments?
__other
If rental units are involved, how many rental units does the landlord have?
IF YOU ARE CLAIMING PUBLIC ACCOMMODATIONS DISCRIMINATION, ANSWER THE FOLLOWING QUESTIONS:
Identify your issue:
__refusal of service __not accessible to disabled __harassment
__different treatment __steering/biased advertising
IF YOU ARE CLAIMING CITY SERVICES DISCRIMINATION, ANSWER THE FOLLOWING QUESTIONS:
What Department was involved?
What is your issue?
__refusal of service __not accessible to disabled __harassment
__different treatment
IDENTIFY YOURSELF IN TERMS OF THE BASIS OR BASES YOU CHECKED OFF, FOR EXAMPLE, "I AM BLACK" OR "I AM A DISABLED PERSON."
IF YOU ARE CLAIMING RETALIATION, ANSWER THE FOLLOWING QUESTIONS:
Did you file a previous discrimination complaint against your employer/landlord? __yes __no
When and what was the basis?
What agency did you file with?
Did you complain of discrimination to management before?__yes __no
When and what were the circumstances?
were you ever a witness in a discrimination case or internal investigation of a discrimination claim?
When and what were the circumstances?
Did you ever complain to management about policies, practices or decisions not directly affecting you being discriminatory? __yes __no
When and what were the circumstances?
PROVIDE A BRIEF DESCRIPTION OF WHAT OCCURRED (Who, what, when - it is important to give dates):
NAMES OF WITNESSES:
NAME _______________________________________________
ADDRESS ____________________________________________
____________________________________________________
TELEPHONE NUMBER ___________________________________
What can the witness attest to?
WHEN FINISHED, PLEASE PRINT OUT AND FAX THIS FORM TO 215-686-4684.
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