New Form

Human Rights Complaint

Use this form to file Human Rights complaints.

Use the checkboxes below to determine if your case is eligible to be considered by Arlington County's Office of Human Rights (OHR).

Requirements for Eligibility

Incident(s) of discrimination occurred within Arlington County. *

Complainants regarding incident(s) of discrimination elsewhere are not accepted, even for County residents.

Latest incident(s) have occurred within the last 180 days. *

The Arlington County Office of Human Rights (OHR) does not accept cases beyond this timeframe.

Email Address *

Email Address (will be used for correspondence)

Human Rights Complaint

Enter the following information. Fields with an asterisk (*) are required.

Your Information

Complaint Type

Name

Work Phone

Home / Cell Phone

Worksite / Location

Applicant First Name

City

State

Zip

Your Home Address

Applicant First Name

City

State

Zip

Additional Contact

This person would know how to reach me if necessary:

Name

Phone

Address

Applicant First Name

City

State

Zip

Human Rights Complaint

Subject of Complaint Information

Against what business or organization do you want to complain?

NOTE: If you would like to submit a complaint against two entities (i.e. a contractor and sub-contractor), you will need to submit two forms. This form will only be used to handle EEO complaints against the subject below.

Business / Organization Name

Type of Business / Organization

Size / Number of Employees

Phone

Address

Applicant First Name

City

State

Zip

Human Rights Complaint

Enter the following information. Fields with an asterisk (*) are required.

Your Employment

Explain how you fit into the organization.

Job Title *

Date of Hire

Date of discipline, termination, or other adverse action *

Your Wage / Salary

If applicable, please specify per hour or annually. This information will be securely encrypted.

Immediate Supervisor Name

Immediate Supervisor Title

Describe your major duties and responsibilities.

Your Colleagues

Who else worked in your department / division? Include name and title.

Name	Title
Name	Title

Name

Title

Export Clear Add new row

Name

Title

Human Rights Complaint

Details of Incident(s)

Enter the following information about the incident(s) of discrimination. Fields with an asterisk (*) are required.

Approximate date(s) of incidents (leave 'to' blank if one-time incident):

Date of Birth

From

Date of Birth

Currently Ongoing

Who discriminated against you?

Include name(s), title(s), position(s).

Why do you believe that you were being discriminated against? Explain what occurred.

Explain WHO did WHAT, WHEN they did it, WHERE it happened, and, in your opinion, WHY it happened. It is helpful to describe the incidents in chronological order.

What remedy are you seeking as a result of this complaint?

What is the normal policy / practice in a situation such as yours?

Is the policy in writing?

Either on paper or online

Yes No Not sure

Upload (if applicable)

Upload

Link (if applicable)

Has anyone else been treated differently than you?

If yes, please describe Who, What, When, Where, and Why. If not, please indicate.

Human Rights Complaint

Upload Documentation

Use this page to upload any files relevant to your case.

Click 'Add File' to add as needed.

Upload File

Upload

File Description

Human Rights Complaint

Use this section of the form to list witnesses, their contact information, and tell us what they can say about your case.

Click 'Next Page' to continue or click the checkbox below to Submit without witnesses.

I would like to submit my application without providing witness information.

Human Rights Complaint

Enter a witness, their contact information, and what the witness can say about your case.

To add another witness, click 'Add Another Witness' at the bottom of the page.

Witness Name

Witness Job Title

Witness Email Address

Witness Phone

Witness Address

Applicant First Name

City

State

Zip

How can this witness help your case?

Add Another Witness

Remove This Witness

Human Rights Complaint

Acknowledgements and Submission

I understand that I have the responsibility to cooperate with the Office of Human Rights (OHR) in order to continue the process of filing a complaint. My failure to do so will result in the termination of this process. *

I understand that if I do not notify this office of any change in my address and telephone number or of any prolonged absence from my address, my complaint may be dismissed. I further understand that if I fail to cooperate fully with this office in the investigation of my complaint my complaint may be dismissed.

By checking this box and typing my name below, I am electronically signing my application. *

Type Name *

Name

Date *

Date

You will be contacted via email or phone when the Office of Human Rights (OHR) has finished reviewing your request. You may also be contacted by the Investigator to provide additional information. Office contact information can be found below.

Arlington Human Rights Commission

2100 Clarendon Blvd, Suite 318

Arlington, VA 22201

(703) 228-3929

(703) 228-4390 (Fax)

https://topics.arlingtonva.us/human-rights/

Human Rights Complaint

Requirements for Eligibility

Human Rights Complaint

Your Information

Additional Contact

Human Rights Complaint

Subject of Complaint Information

Human Rights Complaint

Reason(s) for Discrimination

Human Rights Complaint

Your Employment

Your Colleagues

Human Rights Complaint

Details of Incident(s)

Human Rights Complaint

Upload Documentation

Human Rights Complaint

Human Rights Complaint

Human Rights Complaint

Acknowledgements and Submission

Powered by Versiform

Human Rights Complaint

Requirements for Eligibility

Human Rights Complaint

Your Information

Additional Contact

Human Rights Complaint

Subject of Complaint Information

Human Rights Complaint

Reason(s) for Discrimination

Human Rights Complaint

Your Employment

Your Colleagues

Human Rights Complaint

Details of Incident(s)

Human Rights Complaint

Upload Documentation

Human Rights Complaint

Human Rights Complaint

Human Rights Complaint

Acknowledgements and Submission

Powered by Versiform

Map Spreadsheet Columns to Import