NH COMMISSION FOR HUMAN RIGHTS
2 INDUSTRIAL PARK DRIVE
CONCORD, NEW HAMPSHIRE 03301
TTD Access: RELAY NH 1-800-735-2964
PUBLIC ACCOMMODATIONS DISCRIMINATION
THIS IS NOT A CHARGE OF DISCRIMINATION. This is a questionnaire which
will give a Commission investigator information about your claim. An investigator must
decide whether you have the basis to file a formal charge. If the investigator needs more
information from you, you will be interviewed by telephone, after we receive your
completed questionnaire. If a Charge is to be filed, the Commission will draft your
charge from the information you provide and will send the charge to you in the mail.
You will then sign the charge under oath and return it to the Commission for
filing/docketing. If the Commission believes you do not have the basis to file a charge of
discrimination, you will be sent a letter explaining why.
Please fill out this form as completely as possible, print out a copy, and mail it to the
You may also FAX your completed questionnaire to us at: 603-271-6339.
Keep a copy of the completed questionnaire for your records.
1. Today’s date:
2. Your Name
City, State, Zip
Telephone numbers at home and work
3. Name, address, telephone number of a relative or friend who would know how to reach
4. When did the alleged discrimination take place? REQUIRED
First Date of Discrimination: Month Day Year
Last Date of Discrimination: Month Day Year
Is the discrimination continuing? Yes No
5. Where did the alleged discrimination take place? (Who is your charge against?)