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Intake Questionnaire

Thank you for filling out this Intake Questionnaire from the Seattle Office for Civil Rights (SOCR). This form provides us with information we can use to help us serve you. It is not a formal complaint. Once we receive your completed questionnaire, we will review it and then contact you for more my Formation. 

To avoid delays in processing, please submit only one Intake Questionnaire to SOCR (either by mail, online, or in person) regarding the same matter.


First Name: Last Name:
Middle Initial:
Street Address:
City: State:
Zip Code: County:
Home Phone: ( ) -
Work Phone: ( ) -
Cell Phone: ( ) -
Which telephone number should we use to contact you? 
Email Address:

How did you hear about SOCR?  
Do you require language interpretation?  
Do you require sign language interpretation?  
Who can we contact if we are unable to reach you?
Name:
Daytime Phone: ( ) -
Relationship:

I believe I have been discriminated against in: (check all that apply)
       
I believe I have been discriminated against because of my:(check all that apply)
What employer, housing provider, business, organization or City of Seattle Department do you believe discriminated against you?
Name:
Street Address:
City: State:
Zip Code: County:
Telephone: () -
Name of person/s whom you believe discriminated against you:
When did this occur (please select a date):
Where did this occur:
What happened to you? How do you feel you were discriminated against? (1,000 characters max)
Have you tried to resolve the issue through a grievance process, due process hearing, or some other method?  
Have you filed a formal complaint with anyone else?  
If yes, please provide date:

Please select one if your complaint relates to Employment or Housing: :