Fillable NH COMMISSION FOR HUMAN RIGHTS 2 INDUSTRIAL PARK (State of New Hampshire)

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NH COMMISSION FOR HUMAN RIGHTS 2 INDUSTRIAL PARK (State of New Hampshire)

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NH COMMISSION FOR HUMAN RIGHTS
2 INDUSTRIAL PARK DRIVE
CONCORD, NEW HAMPSHIRE 03301
603-271-2767
FAX 603-271-6339
TTD Access: RELAY NH 1-800-735-2964
Email: humanrights@nh.gov
PUBLIC ACCOMMODATIONS DISCRIMINATION
INTAKE QUESTIONNAIRE
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
above address.
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
Address
City, State, Zip
Telephone numbers at home and work
Email address
3. Name, address, telephone number of a relative or friend who would know how to reach
you:
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?)
Name
Address
Telephone
6. What kind of establishment is it?
Did the discrimination take place at one of the following kinds of establishments
(check one or more that apply)?
Inn, tavern, or hotel
Restaurant or eating house
Public conveyance on land or water
Bathhouse
Barbershop
Theater
Golf course Sports arena
Health care provider
Music or other public hall
Store
Other establishment which caters to the general public
Other establishment which offers its services, goods, or facilities to the general public
(a) Did the discrimination take place at an institution or club which is in its nature
distinctly private? Yes No
(b) Did the discrimination take place at (1) a religious or denominational institution or
organization, or (2) at any organization operated for charitable or educational purposes
which is operated, supervised or controlled by or in connection with a religious
organization?
Yes No
If yes, did the organization discriminate on the basis of religion? Yes No
(If Yes, please describe what action was taken:
(c) Do you believe you were discriminated against on the basis of any of the following:
(Check any that apply?) please specify
Race or color: National origin: Creed (Religion): Marital Status:
Sex (includes harassment or pregnancy): Sexual orientation:
Physical disability:
Mental disability: Gender Identity:
Age: (give age of person discriminated against)
Other, specify:
If you checked Race: Please indicate your race:
If you checked National Origin: Please indicate your National Origin
The following question is voluntary if not checked above:
What is your Race? What is your National Origin?
7. Who took the discriminatory action against you? Please provide their name, if
possible, and their position/job at the place of public accommodation?
8. Was the discrimination any of the following?
a.
Refused, withheld, or denied accommodations, advantages, facilities or
privileges
b.
Published, circulated, issued, displayed, posted, or mailed a discriminatory written
or printed communication, notice or advertisement if checked, what did the
statement, notice or ad say?
c.
Made statements indicating that patronage or custom of a person was
unwelcome or would be refused because of a person’s age, sex, race, color,
religion, disability, marital status, national origin, or sexual orientation. Please
specify what statements were made:
d.
Other discriminatory action you believe occurred:
9. Were any witnesses present? Please provide their names and addresses if
possible.
10. How were you injured by the discriminatory actions?
11. Please provide any other details of your charge that you have not told us
above:
FOR AGENCY ACTION ONLY
Action taken:
[ ] Charge taken [ ] Not a covered basis
[ ] Information only [ ] Actions complained of do not state
[ ] Not a timely charge valid claim
[ ] CP is a federal employee [ ] No employer/employee relationship
[ ] CP chose not to file [ ] Referred to another agency:
[ ] Not enough employees
[ ] Charge already filed at another [ ] other reason (specify):
Agency
[ ] Civil action already filed in court on
same basis
Investigator’s initials: Date: Letter sent:
Date: Initials:
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NH COMMISSION FOR HUMAN RIGHTS 2 INDUSTRIAL PARK (State of New Hampshire)

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Completed 21 July 2020

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