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City of Sioux Falls

noreply@siouxfalls.gov

231 N Dakota Ave, Sioux Falls, SD, 57106, US

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SIOUX FALLS HUMAN RELATIONS COMMISSION
INSTRUCTIONS FOR COMPLETING INTAKE QUESTIONNAIRE

—PLEASE READ THIS ENTIRE DOCUMENT BEFORE STARTING—

The Code of Ordinances of Sioux Falls, SD, Chapter 98, prohibits discrimination on the basis of race, color, creed, religion, sex, national origin, ancestry, disability, or familial status. The Ordinance applies to the following areas: employment, housing, education, public accommodations, public services, property rights, and labor union membership. In order to file a complaint, you must allege discrimination because of your race, color, creed, religion, sex, national origin, ancestry, disability, or familial status (housing only) in the areas of employment, housing, education, public accommodations, public services, property rights, and/or labor union membership. Your charge must be filed within six months from the last date of discrimination. If the last incident of employment discrimination is more than 180 days, but less than 300 days, please contact the Human Relations Commission office before completing the questionnaire.

The Sioux Falls Human Relations Commission is responsible for the administration and enforcement of civil rights laws in the city of Sioux Falls. The Human Relations Office serves as a neutral third party who gathers facts relevant to your case. Our role is to impartially investigate your complaint and work to resolve any grievance through informal means such as mediation and/or conciliation. Our office does not provide legal representation and cannot endorse any particular attorney.

If you believe you have been the target of unlawful discrimination, you may file a charge or complaint of discrimination. You should be prepared to provide specific details pertaining to the alleged discrimination. The first step in the process requires that you complete the attached/enclosed form in its entirety. Use the reverse side and/or extra paper to explain exactly what happened to you. Be specific with all names and dates.

Please note that completing this questionnaire does not mean that a Charge of Discrimination has been filed. After you submit the information, the Human Relations Office staff will review the information, draft a Charge of Discrimination, and then arrange for you to review it and, once finalized, sign it in front of a notary. If the information provided in the questionnaire is not sufficient to draft a charge, you will be contacted to discuss your allegations further.

Please return the completed questionnaire to: Sioux Falls Human Relations Commission,

PO Box 7402, Sioux Falls, SD 57117 or email to humanrelations@siouxfalls.org.

Sioux Falls Human Relations Commission Intake Questionnaire

1. Your Information

(Complainant):

Full Address

Date of Birth

Provide the name of someone who lives at a different address, who would know how to contact you at any time:

Full Name

Full Address

Are you represented by an attorney?

If yes, complete the following:
Please note that you are not required to be represented by an attorney. You can, however, seek representation at any time. Our office does not provide legal representation.

Name of Attorney:

Firm Address

2. Who You Believe Discriminated and/or Retaliated Against You (Respondent):

Provide the name and address of the company, employer, labor union, employment agency, school, business, or public service agency you believe discriminated and/or retaliated against you:

Full Name

Full Address

If the company’s headquarters are located at an address different from the one listed above, please provide the following information (if known):

Company headquarters:

3. Basis of Complaint:

Check the category(s) which best describes the basis for your claim of discrimination. This is the reason you were discriminated against.

Only answer the following questions IF they pertain to the basis of your complaint. For example, if race is the reason you were discriminated against, please identify your race

4. Did you experience retaliation as a result of asserting your civil rights?

5. Disability Information:

Complete the next three questions only if you are claiming disability as the basis for your complaint:

6. Date(s) of Alleged Discrimination Action:

Beginning Date

Ending Date

Is the Alleged Discrimination Action Ongoing?

7. Statement of Allegations:

Describe the discrimination action against you:

8. Reason for Action(s) stated by Respondent:

9. Employment Information: Complete only if Respondent is your current, former, or potential employer.

b. Did you meet the stated qualifications for the position?

c. Were you interviewed?

d. If you were not hired or promoted, do you know who was?

j. Were you given a copy of the company’s rules and policies?

k. Did you ever complain to your supervisor or Human Resources about the discriminatory acts against you?

10. Witness(es):

List any and all persons who witnessed the discrimination and can support your allegations:

Witness Name

Witness Name

11. List other persons (if any) who were discriminated against in the same manner as you.

Provide the following information for each individual.

Full Name

Full Address

Full Name

Full Address

12. Have you filed similar complaints with any other governmental agency?

(i.e., South Dakota Division of Human Rights or Equal Employment Opportunity Commission)?

13. Mediation Information:

Are you interested in pursuing mediation as an alternative to the investigative and formal decision-making process?

The goal of mediation is to arrive at a reasonable settlement that is acceptable to all parties. The Sioux Falls Human Relations Commission supports mediation and strongly recommends you consider it. If you and Respondent agree to enter into mediation, a trained, professional mediator will be provided at no cost to you. If for some reason mediation does not result in a mutual settlement, your charge will then continue through the administrative process, pursuant to City Ordinance.

The Sioux Falls Human Relations Commission does not charge any fees for its services. As a government agency, the Commission and Human Relations Office cannot act as your attorney and cannot endorse or recommend any particular attorney.

Please upload/attach any supporting evidence and documentation.

Click Here to Upload

I certify by checking this box I intend to file a charge of discrimination, and I authorize the Sioux Falls Human Relations Commission to look into the discrimination described above. I understand that the Sioux Falls Human Relations Commission must give the Respondent that I accuse of discrimination information about the charge, including my name. I also understand that the Sioux Falls Human Relations Commission can only accept charges of discrimination based on race, age, sex/gender, national origin, religion, color, disability, familial status, creed, ancestry, genetic information, or retaliation for opposing discrimination.

I declare and affirm that this information is, to the best of my knowledge, true and correct.

Signature of Complainant

Choose how to sign

Full Date