EPHRC INQUIRY QUESTIONNAIRE

The primary purpose of this questionnaire is to obtain preliminary information to aid in determining the nature of assistance needed. Based on the information provided, a determination can be made on the nature of the complaint, whether it is related to housing or employment discrimination, which will require us to collect the demographic information requested below.

If the EPHRC is unable to help resolve a complaint through the conciliation process, the information collected in this form will assist in determining which entity, if applicable, to direct the complaint.

Please note that providing this information is voluntary, but if not provided, it may impede EPHRC’s subsequent investigation.

General Information

Name

First Name

Last Name

Gender

Age

Phone

(###)

###

####

Street Address

County or City

Zip Code

Family Size

Complete Household Size

Race/Ethnicity and Income

Employment Status

Total Household Income

Female Head of Household

What is your race/ethnicity?

Reason for Complaint

HOUSING

EMPLOYMENT

Summarize Complaint

In your words, describe the alleged discriminatory incident. Please include details such as date(s), action(s), name(s), and title(s) of the person(s) whom you believe discriminated against you.

Acknowledgements

Read the statements below and confirm understanding with a check mark.

By submitting this form, I understand that filing a discrimination complaint with the Escambia Pensacola Human Relations Commission is NOT THE SAME as filing a complaint with HUD, EEOC, or Florida Commission on Human Relations.

Permission is granted to the EPHRC to investigate on your behalf and to have access to all records pertaining to or necessary to investigate this allegation.

Lastly, I do certify that the statements made in this complaint are true and accurate to the best of my knowledge.

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