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  PUBLIC ACCOMADATION COMPLAINT QUESTIONNAIRE
  Instructions for Complainants                                      Return to –Compliance Section
 

(1) Try to answer every question in the sections which apply to your complaint and give complete and detailed responses.

(2) Think carefully before answering each question.

(3) When you're done, click the "Submit" Button at the bottom of the form.

(4) This is not a formal complaint form. The Human Rights Office will determine whether you have submitted enough information to file a formal complaint. The Human Rights Office will send you a completed formal complaint for signature and notarization if you have provided sufficient evidence.

Sections A, B, and D must be completed. Fill out the rest of the sections that apply to you.

(*) required fields

 

Section A
Complainant Information - Person(s) filing complaint
*First Name:
  
Middle Initial:
*Last Name:
  
*Birthdate:
  
Age:
*Home Address:
 
*City:
  
*State:
*Zip Code:
    
*Home Phone Number:
(123-345-6789)
    
E-Mail Address
  
Fax Number:
Cell Phone/Pager:
(123-345-6789)
  
Business Address:
City:
State:
Zip Code:
  
Business Phone Number:
(123-345-6789)
  

 

Complainant's Attorney Information
Attorney's Name:
Office Address:
City:
State:
Zip Code:
  
Office Telephone Number:
(123-456-7890)
  
What other agencies/organizations have you contacted for assistance??
 
Were you given a Case Number?
Yes (if yes, what is the case No.)

 

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Section B
Respondent - Any owner, lessee, operator, manager, agent, or employee of any place of public accommodation, resort, or amusement. (Person, Persons, Company which committed act of discrimination)
*Name of Respondent:
  
  (indicate if incorporated, limited partnership, etc.)
*Respondent's Address:
  
*City:
  
*State:
*Zip Code:
    
Telephone Number:
(123-345-6789)
  
 
If the actual place where the discrimination occurred is a different site than the Respondent's address listed above, provide the address where it happened: (NOTE: It MUST be located in Montgomery County, MD)
Address:
City:
State:
Zip Code:
  
Telephone Number:
(123-345-6789)
  
   
Corporate Name of Respondent (if known):
  (indicate if incorporated, limited partnership, etc.)
Corporate Address:
City:
State:
Zip Code:
  
Corporate Telephone Number:
(123-345-6789)
  

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Section C
Disability
Are you alleging discrimination based on disability?
 If No skip this section

Describe how the Respondent became aware of your disability.
 
When did the Respondent become aware of your disability?
 
Did you speak with the Respondent's  facility about your disability?
Name:
  
Does the Respondent believe/perceive that you have a disability?

What accommodation, if any, did you request from the respondent?

How did the respondent  respond to your request for an accommodation of your disability? ( i.e. was your request denied, did the respondent tell you the accommodation was too costly, did the respondent off your an alternative (specify), did the respondent tell you it would take more time, did the respondent tell you any modifications would be at your expense, etc ).

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Section D
General Information :
*When did the alleged discriminatory act occur?  
 
What was the discriminatory basis for the Respondent's action(s)?
 
   
  

Why do you believe the Respondent's action(s) were discriminatory? Provide a detailed explanation showing the connection between the action(s) and the basis for your claim.

 

Did you know if any persons were treated differently than you? Provide a detailed explanation giving name(s) and describe how these persons are different than you (ie. sex, race, national origin, age, etc.) [if you don't know the person's name, give whatever information you can to identify the person]

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Section E
Pricing
If your complaint involves the pricing of merchandise or services, please describe the merchandise or services you purchased or attempted to purchase, the listed price for the merchandise or services, the actual price you paid or were quoted for the merchandise or services, and why you believe this price was discriminatory.

For complaints involving the pricing of merchandise or services, please identify persons who received the same and/or different price quotes for the same merchandise or services you sought. [if you don't know the person's name, give whatever information you can to identify the person.]
Name
Relationship to you
Address
Description (race, sex, nationality, etc.)
Home Phone

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Section F
Denial or refusal of Service
Were you given a reason for being denied or refused service?
How were you notified that you were denied/refused service? Please describe what happened.

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Section G
Advertising
If your complaint involves discriminatory real estate advertising, explain how you were effected by the discrimination and describe the advertisement.

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Section H
Quality of Merchandise or Service
If your complaint involves the quality of merchandise or services provided, please give a detailed description of the product or service which is normally available and the product or service which you actually received.
Why do you believe this difference is discriminatory? Provide a detailed explanation showing the connection between the action(s) and the basis for your claim.

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Section I
Supporting Information
Did you complain to any company official about your treatment?
How and when did you talk to a company official, who was it, and what was their response?
Describe any comments you believe were proof of discriminatory intent and identify who made the comments and when the comments were made. Be specific.
Are there any other persons who have information about events which led you to believe you were being discriminated against? If so, identify each person and specifically describe what each person will tell the Commission.
Name
Relationship to you
Address
Description (race, sex, nationality, etc.)
Home Phone
If you have other information you wish to present to the Office at this time to describe the circumstances surrounding your complaint of discrimination, please do so in the space below:

*Note : This is not a formal Complaint form.