| INFORMATION ON ALLEGED VICTIM OF DISCRIMINATION | CONFIDENTIALITY REQUESTED? Y N | |||||
| NAME | TELEPHONE DISCRETION
Day Evening |
|||||
| STREET ADDRESS | CITY, STATE, ZIP CODE | |||||
| INDIVIDUAL SELF-IDENTIFIES
AS
__ GAY __ LESBIAN __ BISEXUAL __ TRANSGENDERED __ HETEROSEXUAL __ OTHER ___________ |
||||||
| NAME OF BUSINESS OR ORGANIZATION WHICH HAS ALLEGEDLY COMMITTED AN ACT OF DISCRIMINATION (If more than one, list below.) | ||||||
| NAME OF BUSINESS OR ORGANIZATION | TELEPHONE | |||||
| STREET
ADDRESS
|
CITY, STATE, ZIP CODE | COUNTY | ||||
| PERSON(S) INVOLVED, TITLE(S) | ||||||
| NUMBER
OF EMPLOYEES (Employment bias only)
__ <4 __ 4-14 __ 15+ __ Unknown |
COUNTY
CONTRACTOR?
__ Yes __ No __ Unknown |
|||||
| NATURE OF THE DISCRIMINATION (Check appropriate box(es)) | ||||||
| __ EMPLOYMENT
__ COUNTY EMPLOYMENT __ HOUSING |
__ PUBLIC
ACCOMMODATIONS
__ EDUCATION __ CREDIT |
__ PROVISION
OF COUNTY SERVICES
__ RETALIATION |
||||
| ADDITIONAL BASES FOR CAUSE OF DISCRIMINATION (Check appropriate box(es) if applicable) | ||||||
| __ RACE
__ COLOR __ SEX |
__ RELIGION
__ NATIONAL ORIGIN __ MARITAL STATUS |
__ AGE
__ FAMILIAL STATUS __ DISABILITY |
||||
| DATE DISCRIMINATION TOOK PLACE | ||||||
| Earliest | Latest | Continuing Action? Y N | ||||
| THE PARTICULARS
ARE (If additional space is needed, attach extra sheet(s)):
|
||||||
| Would you have done something different if there were protections? | __ Yes __ No __ Unknown | |||||
| INFORMATION TAKEN BY | ||||||
| Name | Date | Time | ||||
| May FACE contact you further? | __ Yes __ No __ Unknown | |||||
| May FACE publicize this incident, with your anonymity protected? | __ Yes __ No __ Unknown | |||||
| Would you be willing to sign an affidavit attesting to these allegations? | __ Yes __ No __ Unknown | |||||
| Would you be willing to testify at a public hearing to these allegations? | __ Yes __ No __ Unknown | |||||
| Will you also contact the Fairfax County Human Rights Commission (703-324-2953) with this information? | __ Yes __ No __ Unknown | |||||
| May we send you postcards and membership information? | __ Yes __ No __ Unknown | |||||
