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Office for Civil Rights Patricia Lally, Director
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Paid Sick & Safe Time
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.

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?
Daytime Phone: ( ) -

Do you work at least some of the time in Seattle?    
I believe my employer has violated the Seattle Paid Sick and Safe Time Ordinance by: :(check all that apply)
Business/Company Information:
City: State:
Zip Code: County:
Telephone: ( ) -
Name of supervisor/s or manager/s:
Date of Hire (please select a date):
Date of Incident (please select a date):
Briefly describe what happened (1,000 characters max)