OEO - PUBLIC ACCOMMODATIONS DISCRIMINATION COMPLAINT QUESTIONNAIRE

Palm Beach County Office of Equal Opportunity
301 North Olive Avenue, 10th Floor – West Palm Beach, FL 33401
Telephone: (561) 355-4883 | FAX: (561) 355-4932 | TDD: (561) 355-1517
https://www.pbcgov.com/equalopportunity

IMPORTANT NOTICE TO POTENTIAL CHARGING PARTY: Completion of this form is necessary in order for the Office of Equal Opportunity (OEO) to determine if you have sufficient legal grounds to initiate the filing of a charge of employment discrimination. Completion and submission of this Questionnaire does not constitute the filing of a charge of discrimination. Upon receipt of this completed Questionnaire, we will determine if you have stated sufficient factual allegations to proceed further. If the facts are not sufficient, we will either contact you for further information or notify you of our determination that the facts are not sufficient. If the facts are sufficient, a complaint will be prepared for you to sign and return to OEO for filing and investigation. You must return the signed complaint form so that is received by OEO within 180 days of the date of the most recent act of alleged discrimination. If your form is received after 180 days, but within 300 days, OEO will forward your forms to the U.S. Equal Employment Opportunity Commission (EEOC) for processing and investigation.

(NOTE: Under Florida law, email addresses are public records. Do not provide your email address if you do not want it released in response to a public records request.)

Personal Information *This question is required.

First Name

Middle Initial

Last Name

Date of birth?

Gender

Racial identity

Street Address

City

County

State

Zip Code

Day Time Phone Number (including the area code)

Evening Phone Number (including the area code)

The name of a person who will know how to reach me is

Their telephone number, including the area code, is

Email address This question requires a valid email address.

NOTE: Under Florida law, email addresses are public records. Do not provide your email address if you do not want it released in response to a public records request.)

How did you hear about us? *This question is required.

Referred by
Attended which outreach event?

Referred by *This question is required.

Attended which outreach event? *This question is required.

INFORMATION ABOUT THE PUBLIC ACCOMMODATIONS PROVIDER

What is the name of the Public Accommodations provider that you believe discriminated against you? *This question is required.

Name

Street Address

City

County

State

Zip Code

Phone Number

What is the location of the business owned/operated by the above-named Public Accommodations provider? *This question is required.

Name

Street Address

City

County

State

Zip Code

Phone Number

NOTE: Under Florida law, email addresses are public records. Do not provide your email address if you do not want it released in response to a public records request.)

The person named above operates a business which serves the public. The business is a: *This question is required.

PLEASE INDICATE THE BASIS UPON WHICH YOU BELIEVE YOU WERE DISCRIMINATED AGAINST (Check and respond only to those that are applicable to your case.): *This question is required.

If your claim is based on race, what is your race? *This question is required.

If your claim is based on color, what is your color? *This question is required.

If your claim is based on national origin, what is your national origin? *This question is required.

If your claim is based on sex (or gender), what is your sex (gender)? *This question is required.

If your claim is based on sexual harassment, did you report the alleged harassment to the Public Accommodations provider? *This question is required.

If yes, what actions did the Public Accommodations provider take based upon your report? *This question is required.

If your claim is based on age, what is your age? *This question is required.

If your claim is based on religion, what is your religion? *This question is required.

Did you request an accommodation for a religious practice or belief? *This question is required.

If yes, what was the Public Accommodations provider’s response to your request? *This question is required.

If your claim is based on retaliation, have you previously filed a place of public accommodation discrimination claim with either DOJ, FCHR or OEO? *This question is required.

Have you previously filed a claim of housing discrimination through the business’ procedures? *This question is required.

Have you testified or assisted someone else in protecting their rights under the public accommodations laws? *This question is required.

If your claim is based on disability, what is your disability?
(NOTE: IF YOUR CLAIM IS BASED ON A DISABILITY, PLEASE COMPLETE THE ATTACHED DISABILITY QUESTIONNAIRE.) *This question is required.

Did you request an accommodation or modification for your disability? *This question is required.

If yes, what accommodation or modification did you request? *This question is required.

If your claim is based on familial status, please indicate the number and ages of your dependent child(ren) that are under the age of eighteen (18): *This question is required.

If your claim is based on marital status, please indicate whether you are: *This question is required.

Please enter an 'other' value for this selection.

If your claim is based on sexual orientation, what is your sexual orientation? *This question is required.

Gender Identity or Expression *This question is required.

The most recent act of discrimination took place on *This question is required.

BRIEF STATEMENT REGARDING YOUR DISCRIMINATION CLAIM

Briefly describe the action that was taken against you that you believe to be discriminatory. Indicate what harm, if any, was caused to you or others in your party or family as a result of this alleged action. *This question is required.

What reason, if any, did the Public Accommodations provider give for the alleged discriminatory treatment? *This question is required.

Why do you believe that the action taken against you was discriminatory? *This question is required.

The names, addresses and telephone numbers for all persons who have knowledge about the alleged discriminatory treatment are listed below. I have also given a summary of what each person knows about this matter *This question is required.

RELIEF / MEDIATION

What relief are you seeking in this matter? *This question is required.

Would you be willing to accept to resolve this matter immediately? *This question is required.

Are you willing to participate in mediation to seek an early resolution of your claim(s)? *This question is required.

EXISTING / PREVIOUS CHARGES

Have you sought assistance from any other agency, attorney, etc.? *This question is required.

If yes, what is the name of the source of assistance? *This question is required.

Date of assistance *This question is required.

Results, if any *This question is required.

Have you previously filed a complaint with OEO or another agency? *This question is required.

If yes, when did you file? *This question is required.

Charge/Complaint No. (if known) *This question is required.

DISCLAIMER

A. I have been advised by a representative of the Palm Beach County Office of Equal Opportunity (OEO) that completion of this Questionnaire is necessary in order for the Office of Equal Opportunity to determine if I have sufficient legal grounds to initiate the filing of a complaint of Public Accommodations discrimination. I understand that completion and submission of this Questionnaire does not constitute the filing of a complaint of discrimination and that upon receipt and review of this completed Questionnaire, OEO will determine if I have stated sufficient factual allegations to proceed with the actual filing of a complaint of discrimination

B. I understand that to be timely filed, a complaint of discrimination must be received by OEO within one (1) year of the date of the most recent act of alleged discrimination.

Under penalty of perjury, I declare that I have read the entire contents of this Questionnaire and that my answers and statements contained herein are true and correct. *This question is required.

Clear

Signature of

Date Signed *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Palm Beach County Office of Equal Opportunity – Complaint Review Process Updated:

Below is an explanation of what you can expect regarding how your complaint will be processed in our office.

You should expect to receive a call or letter from the Equal Opportunity Specialist (EOS) assigned to your complaint within 30 days from the date we received your completed employment discrimination intake questionnaire. Depending on the type of complaint and the issues associated with your complaint, the review process may take several weeks after we have all the needed information to process your complaint.
All complaints received are not accepted and referred for investigation.
The EOS does NOT communicate or make contact with the person(s) you are complaining about during the review process.
We do NOT advocate or represent you (the complainant(s)) or the person(s) you are complaining about (respondent(s)).
We conduct a review of your complaint to determine if the issue(s) you are complaining about meet the jurisdictional or allowable requirements of the fair housing laws.
You will be asked to answer specific questions which are necessary for us to determine if your complaint can be accepted and referred for investigation.
You will also be asked to provide documents necessary to complete the review of your complaint.
Be advised that our office is responsible for reviewing all complaints received for all persons making a complaint involving allegations of housing discrimination within Palm Beach County. We process complaints in the order received. Therefore, in the interest of assuring a thorough review of your complaint, your patience is appreciated.

Complaints NOT Accepted for Investigation:
IF after reviewing your complaint and documents, it is not accepted for referral for investigation:

You will receive correspondence giving you the reason(s) why your complaint was not accepted for investigation and why the file will be closed.
In some instances, we may refer you to a different County department or outside agency that may be able to help you with your non-jurisdictional complaint.

Complaints Accepted and Referred for Investigation:
IF your complaint is accepted and referred for investigation:

The EOS will prepare the formal charge of discrimination for your signature. The summary of allegations will be written in a different format from the information you originally provided.
Additionally, the charge will include your name and address and the name and address of the business alleged to have violated equal employment law(s).
You should review the document carefully to ensure that it is consistent with your allegations, sign it and return it to the EOS as soon as possible (ASAP). If you do not agree with the summary of allegations, do NOT write on the actual document, you should contact the EOS ASAP.
If you do not return the signed charge your case will NOT be referred for investigation, therefore, it will be closed due to your failure to respond.
Upon receipt of the signed charge, the EOS will send you and the business you complained about a formal letter giving you the case name, number and the contact information regarding the investigation. The EOS then transfers your file for investigation and the EOS no longer has responsibility for your file or regarding your case.
Your case will be pending assignment to an investigator after we receive the signed charge from you and response from the business. Please note that it may take several months after we receive the response from the business before the case is assigned to an investigator as we generally assign cases in the order in which they are filed. All further communication should be with the assigned investigator.
The assigned investigator will then contact you and the business you complained about to begin the investigation.
You should keep all documents related to your charge such as receipts, letters, newspaper or internet ads, telephone numbers, tapes, photos, etc. in a safe place because the assigned investigator will need them. PLEASE NOTE THAT INFORMATION PROVIDED TO THE OEO ARE PUBLIC RECORDS AND OPEN TO THE PUBLIC AS PROVIDED BY LAW. DO NOT PROVIDE OEO WITH RECORDS YOU DO NOT WANT TO BE PUBLIC.
You will also be asked to write down a timeline of what happened that led you to file the complaint. The timeline will assist the investigator in the investigation.
The assigned investigator will also discuss options for settlement of your case if both parties agree to participate in conciliation.

We appreciate your patience and cooperation. Thank you.