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TEST - Paid Sick & Safe Time (PSST) Intake Questionnaire

Thank you for filling out this questionnaire from the Seattle Office for Civil Rights (SOCR).
THIS IS NOT A FORMAL COMPLAINT. This form provides us with information we can use to help us serve you. Once we receive your completed questionnaire, we will review it and then contact you for more information. 

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

Incident Date*: (please select a date)
First Name*:
Middle Initial:
Last Name*:
Street Address*:
City*: State:
Zip Code*: County:
Home Phone*: ( ) -
Work Phone: ( ) -
Cell Phone: ( ) -
Which telephone number should we use to contact you? 
Email Address:
Who can we contact if we are unable to reach you?
Daytime Phone: ( ) -

How did you hear about SOCR?* 
Do you require language interpretation?  
Do you require sign language interpretation?  

I believe my employer has violated the Seattle Paid Sick and Safe Time Ordinance by*:
(check all that apply)

Do you work at least some of the time in Seattle?*: Yes      No
Business Name*:
Name of Supervisor/Manager(s):
Street Address*:
City*: State:
Zip Code*: County*:
Telephone: ( ) -
Briefly describe what happened* (1,000 characters max)

Please note that you have 180 days to file a charge with the Seattle Office for Civil Rights. You are protected from retaliation under the PSST Ordinance.

Accommodations for people with disabilities and
language interpretation provided upon request.
810 Third Avenue, Suite 750, Seattle, WA  98104
Telephone: (206) 684-4500, TTY: (206) 684-4503, Fax (206) 684-0332

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