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CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING
INTAKE FORM
HOUSING
The completion and submission of this Intake Form will initiate an intake interview with a
Department of Fair Employment and Housing (DFEH) representative. The Intake Form is not a
filed complaint. The DFEH representative will determine if a complaint can be accepted for
investigation. Your submission of this document acknowledges that you have read and agree to
the DFEH’s Privacy Policy.
COMPLAINANT:
NAME: TELEPHONE NUMBER:
ADDRESS: EMAIL ADDRESS:
CITY/STATE/ZIP:
Do you need a translator during the complaint process? Yes No
If yes, indicate language
RESPONDENT:
NAME: TELEPHONE NUMBER:
ADDRESS:
CITY/STATE/ZIP:
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ADD CO-RESPONDENT:
NAME:
TITLE:
ADDRESS:
TELEPHONE NUMBER:
FIRST DATE OF HARM (Month/Day/Year):
LAST DATE OF HARM (Month/Day/Year):
FULL PROPERTY ADDRESS WHERE VIOLATION OCCURRED
NUMBER OF UNITS IN THE HOUSING COMPLEX:
PROPERTY DESCRIPTION:
Apartment
House
Trailer Space or Mobile Home
Vacant Lot
Condominium
Other (specify)
FULL NAME AND AGE OF ALL CHILDREN IN THE HOUSEHOLD UNDER THE AGE OF 18:
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1. I ALLEGE THAT I EXPERIENCED: Discrimination Harassment
BECAUSE OF MY ACTUAL OR PERCEIVED:
Ancestry
A
ssociation with someone of a protected class
Color
Disability (physical or mental)
Familial status (children)
Gender identity or expression
Genetic information
Marital status
Military and Veteran Status
National Origin (includes language restrictions)
Race
Religious creed (includes dress and grooming practices)
Sex/Gender
Sexual harassment Hostile environment
Sexual harassmentQuid Pro Quo
Sexual orientation
Source of income
Other (specify): _________________________________________________________
AS A RESULT, I WAS:
Denied equal terms and conditions
Denied loan/home owners insurance
Denied reasonable accommodation for a disability or medical condition
Denied reasonable accommodation for religious creed
Denied rental/sale/lease
Evicted
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Subjected to discriminatory statements/advertisement
Subjected to discriminatory zoning/land use
Subjected to restrictive rule/covenant
Other (specify): ________________________________________________________
I ALLEGE THAT I EXPERIENCED: Retaliation
BECAUSE I:
Participated as a witness in a discrimination or harassment complaint
Reported or resisted any form of discrimination or harassment
Requested or used a disability-related accommodation
Requested or used a religious accommodation
AS A RESULT, I WAS:
Denied equal terms and conditions
Denied loan/home owners insurance
Denied reasonable accommodation for a disability or medical condition
Denied reasonable accommodation for religious creed
Denied rental/sale/lease
Evicted
Subjected to discriminatory statements/advertisement
Subjected to discriminatory zoning/land use
Subjected to restrictive rule/covenant
Other
(specify): ________________________________________________________
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2. Do you have an attorney who agreed to represent you in this matter? Yes No
If yes, please provide the attorney’s contact information.
COMPLAINANT’S REPRESENTATIVE INFORMATION
Attorney Name:
Attorney Firm Name:
Attorney Address:
Attorney City, State, and Zip:
3. Briefly describe what you believe to be the reason(s) for the discrimination, harassment, or
retaliation. (Optional)
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DEMOGRAPHIC INFORMATION
THIS INFORMATION IS OPTIONAL AND IS ONLY USED FOR STATISTICAL PURPOSES.
Primary Language: Age:
GENDER / GENDER IDENTITY:
Male Female Non-Binary
MARITAL STATUS:
Single Married Cohabitation Divorced
RACE:
American Indian, Native American or
Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
ETHNICITY:
Hispanic or Latino Non-Hispanic or Latino
NATIONAL ORIGIN:
Afghani
American [U.S.A]
Asian Indian
Bangladeshi
Cambodian
Canadian
Chinese
Cuban
Dominican
Egyptian
English
Ethiopian
Fijian
Filipino
German
Ghanaian
Guamanian
Haitian
Hawaiian
Hmong
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Jamaican
Japanese
Korean
Laotian
Lebanese
Malaysian
Mexican
Nigerian
Other
Other African
Other Asian
Other Caribbean
Other European
Other Hispanic/Latino
Other Middle Eastern
Pakistani
Puerto Rican
Salvadoran
Samoan
Sri Lankan
Syrian
Taiwanese
Thai
Tongan
Vietnamese
Other
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DEMOGRAPHIC INFORMATION
THIS INFORMATION IS OPTIONAL AND IS ONLY USED FOR STATISTICAL PURPOSES.
DISABILITY:
AIDS or HIV
Blood / Circulation
Brain / Nerves / Muscles
Digestive / Urinary / Reproduction
Hearing
Heart
Limbs [Arms / Legs]
Mental
Sight
Speech / Respiration
Spinal / Back / Respiration
Other Disability
RELIGION:
Agnostic
Atheist
Bahai
Buddhism
Catholicism
Christianity
Confucianism
Hinduism
Islam
Jehovah's Witness
Judaism
Neo-Paganism
Nonreligious
Protestantism
Primal-indigenous
Quakers
Rastafarianism
Spiritism
Shinto
Sikhism
Taoism
Unitarian-Universalism
Zoroastrianism
Other
Straight or Heterosexual
Gay or Lesbian Bisexual
Other
SEXUAL ORIENTATION:
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CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT & HOUSING PRIVACY POLICY
The California Department of Fair Employment & Housing (DFEH) has adopted this Privacy
Policy, effective January 1, 2017. DFEH values the security and privacy of your personal
information and is committed to protecting your privacy rights. The DFEH seeks only to collect
relevant personal information that enables us to assist you in investigating and resolving
complaints of discrimination as prescribed by California Government Code sections 11135 et
seq., 12900 et seq., and California Civil Code sections 51, 51.7, 52.5, and 54 et seq.
All personal information we collect is governed by the State of California Information Practices
Act of 1977 (Civ. Code, §§ 1798-1798.78), Government Code sections 11015.5 and 11019.9,
and the California Public Records Act (Gov. Code § 6250 et seq.).
Outlined below is our online Privacy Policy and Notice:
Legal Authority for Collection and Use of Information
Disclosure and Sharing
What happens to information you submit to us?
Cookies
Links
Public Disclosure
Minors
Security
Access and Corrections to your Personal Information
How to contact us if you have any questions regarding this policy
Changes to our Privacy Policy
Effective date
Legal Authority for Collection and Use of Information
We collect information that may be directly associated with a specific person. We call this
"Personal Information," and it includes, names, addresses, telephone numbers and email
addresses. We collect this Personal Information through lawful means from individuals who
seek to file a complaint with the DFEH, and we use this information to establish jurisdiction and
to conduct an investigation of any allegations of Civil Rights violations. If you seek to file a
complaint, you are required to provide us with sufficient information in accordance with
California Government Code sections 11135 et seq., 12900 et seq., and California Civil Code
sections 51, 51.7, 52.5, and 54 et seq.
Disclosure and Sharing
We do not sell your personal information. Government Code section 11015.5, subdivision (6),
prohibits DFEH and all state agencies from distributing or selling any electronically collected
personal information about users to any third party without the permission of the user. Any
distribution of electronically collected personal information will be solely for the purposes for
which it was provided to us, as described below.
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We also may share your personal information under the following circumstances:
1. You give us permission.
2. We receive a request from a party with legal authority to obtain the information, such as a
subpoena.
3. As authorized by law, it is transferred to / shared with the U.S. Equal Employment
Opportunity Commission, the National Labor Relations Board, the U.S. Department of
Labor, the U.S. Department of Housing and Urban Development, the U.S. Department of
Health and Human Services, the U.S. Department of Education, the U.S. Department of
Justice, or any branch of the California State Government, or any other local or Federal
agency with similar jurisdiction.
4. Non personal information, including the allegations in the complaint document itself, may
be disclosed to the public under the California Public Records Act.
What happens to information you submit to us?
The Personal Information we obtain from you will be used for the purposes for which it was
provided: to further the DFEH’s efforts to investigate and attempt to resolve the allegations of
unlawful discrimination, harassment and/or retaliation that you filed. Electronically collected
Personal Information we gather about visits to our website is used to help us improve the user
experience and for basic web metrics of our website.
Links
Our website may contain links to other websites on the Internet that are owned and operated by
third parties. DFEH does not control the privacy policies or practices of these websites. You are
advised to review the privacy policies of the third party offering the website before providing any
personal information to these websites. DFEH is not responsible for the content or practices of
any linked third party website and such third party websites are provided solely for the
convenience and information to our visitors.
Cookies
We do not collect information such as names, addresses, and emails from individuals browsing
DFEH’s website. However, when you visit our website, a “cookie” may be saved on your
computer. A cookie is a tiny piece of data stored by your browser that helps us recognize your
unique computer and your preferences when using our website. The information DFEH
automatically collects may include the type of browser used, date and time you visited the site,
and web pages you visited. This information is collected to improve the user experience and for
basic web metrics. The information is deleted after 30 days. This type of electronic information
collection is permitted by law and is exempt from requests made under the Public Records Act.
You can refuse the cookie or delete the cookie file from your computer after you visit our
website. You can find instructions for managing cookie controls on websites for particular
browsers. For example:
Microsoft Internet Explorer browsers
Macintosh Safari browsers
Mozilla Firefox browsers
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Public Disclosure
In the State of California, laws exist to ensure that government is open and that the public has a
right to access appropriate records and information possessed by state government. At the
same time, there are exceptions to the public's right to access public records.
These exceptions serve various needs including maintaining the privacy of individuals. Both
state and federal laws provide exceptions. All information collected at this site becomes a public
record that may be subject to inspection and copying by the public, unless an exemption in law
exists. In the event of a conflict between this Privacy Notice and the Public Records Act, the
Information Practices Act and/or other law governing the disclosure of records, the Public
Records Act, the Information Practices Act and/or other applicable law will control.
Minors
We recognize the importance of protecting privacy where minors (a person under 18 years of
age) are involved. We are committed to protecting the privacy of minors and do not knowingly
collect personal information from minors or create profiles of minors through our website. Users
are cautioned, however, that the collection of personal information submitted online or in an e-
mail will be treated as though it was submitted by an adult. DFEH strongly encourages parents,
guardians and adults to be involved in the internet activities of their children or other minors they
are responsible for and to provide guidance whenever minors are asked to provide personal
information online. If you believe a minor has provided us with personal information, we ask that
a parent or guardian contact us at 1-800-884-1684.
Security
DFEH has put security measures in place to safeguard and protect your information from
unauthorized access, disclosure, and loss. Our policy limits access to personal information to
employees who have an established business need for the Personal Information including those
directly involved in the filing, investigation, resolution and/or litigation of your complaint.
Information that is physically located within the DFEH is protected by various security measures,
which may include the use of encryption software to protect the security of an individuals’
personal information during transmission and storage. Personal Information is destroyed
according to the DFEH’s records retention policy, and we only retain these records for as long
as necessary to fulfill our business need. We train our employees on procedures and
management of personal information we collect as well as on taking precautions and complying
with limitations on the release of personal information.
Access and Corrections to your Personal Information
You have the right to review any Personal Information we collect about you. If you request all or
a portion of the Personal Information collected about you by the DFEH, we will provide you with
the Personal Information requested and explain how we use the information. You may request
changes to your Personal Information you believe is incorrect by submitting a written request
that credibly shows the error. If you believe that your Personal Information is being used for a
purpose other than what you intended when you submitted it, you may contact us so we can
rectify the misuse. In all cases, we will take reasonable steps to verify your identity before
granting access or making corrections.
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How to contact us if you have any questions regarding this policy
If you have any questions or concerns about the information presented in this Privacy Notice,
you may contact:
DFEH Privacy Officer
2218 Kausen Drive, Suite 100
Elk Grove, CA 95758
1-800-884-1684
Changes to our Privacy Policy
We may update and revise our Privacy Policy. We will post any privacy policy changes on this
page and, if the changes are significant, we will provide a more prominent notice.
Effective date
January 1, 2017
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