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City of Sioux Falls

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

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Sioux Falls Human Relations Commission

Discrimination Intake Questionnaire

PLEASE READ: This form is not an official complaint. This form is used to obtain information prior to the complaint process that will help determine whether the Human Relations Commission has jurisdiction over your matter. If an official complaint is filed, the organization/person identified as the Respondent on this form will be served with a copy of your official complaint.

The Discrimination Intake Questionnaire Instructions are provided to assist you in completing this form and contain important information for you to consider as you answer the questions.

It is important that you fill out this form as completely and truthfully as possible. Any false statements or failure to disclose information may be detrimental to your case and may result in an adverse finding.

INTAKE ACKNOWLEDGMENTS

Please read the statements in this section carefully and mark to indicate your acknowledgement. These acknowledgments must be completed for a questionnaire to be accepted and a complaint to be processed.

To file, you must mark “Yes” to indicate that you acknowledge the following:

I am the “Charging Party” and I understand I carry the initial burden of proof.

I understand information I submit may be shared with the person/organization who I am alleging discriminated against me.

I understand the information I submit must be complete and I must provide sufficient information for the Commission to pursue my charge, and my failure to provide the requested information may result in the rejection of this form.

I understand I am providing information to the Commission to determine if I have met the requirements for filing a charge, and the act of submitting this information does not guarantee a case will be opened.

I have read the Discrimination Intake Questionnaire Instructions and understand the process and what is expected with completing this Intake Questionnaire.

I agree to keep the Commission apprised of my up-to-date contact information, to cooperate fully with any investigation, and to promptly respond to Commission inquiries and requests.

PART 1: COMPLAINANT INFORMATION

This section is to provide the Human Relations Commission with necessary identifying and contact. Fields marked with red asterisks are required.

Note: You are not required to have an attorney to file a discrimination complaint with the Sioux Falls Human Relations Commission. The Commission cannot provide you with legal representation or legal advice. You are welcome to obtain legal representation or seek legal advice from an attorney at any time during the complaint process.

Preferred Contact Method:

Are you represented by an attorney?

PART 2: DISCRIMINATION INFORMATION

This section is to explain to the Human Relations Commission the reason you believe you were discriminated against. Discrimination is the unfair or unequal treatment of an individual because of a personal characteristic as described in Chapter 98 of the Code of Ordinances of the City of Sioux Falls.

Note: Not all unfair, disrespectful, unprofessional, or inconsiderate behavior meets the legal threshold for unlawful discrimination. A charge of unlawful discrimination requires a negative or unfair action or practice to have occurred because of an individual’s membership in a protected class.

AREA:

This section asks you to identify which protected area the discrimination occurred in.

“Public accommodations” are defined as the services and facilities of any and all places of business engaged generally in the provision of services or goods to the public, or generally soliciting public patronage. Public accommodations include but are not limited to theaters, hotels, motels, restaurants, taverns, barbershops, beauty shops, insurance companies, lending organizations, financial institutions, and carriers.

“Public services” are defined as the services or facilities provided within the city to the public including those provided by any public facility, department, agency, board or commission, owned, operated, or managed by or on behalf of the state, any political division thereof, or any other public corporation.

“Education” is defined as any university, college, or school operating within the city including any school, institution, or organization for vocational training. Education does not apply to the students of, or the education provided by, any school maintained and operated by a religious corporation or association provided solely for the benefit of its own membership.

If the discrimination occurred in housing or employment, please contact the Human Relations Office to receive the appropriate intake questionnaire.

Where did the discrimination occur?

BASIS:

The Commission processes complaints in which discrimination has allegedly occurred because of one or more of the following:

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Note: If you believe you were treated differently for a reason other than what is listed above, the Commission would not have jurisdiction over your matter. Failure to identify a protected basis for the alleged discriminatory act will result in an inquiry being screened out due to a lack of jurisdiction.

Check the category that describes the basis for your claim of discrimination, or the reason you feel you were discriminated against. For each category you select, please indicate how you identify within that category. NOTE: If none of the following apply, please stop here.

RETALIATION:

“Retaliation” is when an individual or organization takes an adverse action against you because you engaged in a protected activity. Protected activities include complaining of discriminatory harassment, reporting unlawful discrimination, or participating in a discrimination proceeding based on your or another person’s membership in a protected class. Protected activity does not include general, non-discrimination related complaints about the organization, their practices, services, or other such matters.

If you are alleging retaliation, please remember to describe the protected activity in which you engaged and the action that was taken against you as a result in Part 4. A complaint alleging retaliation must meet the above-described criteria to be filed.

Do you believe you were retaliated against because you reported discrimination to someone within the organization, filed a complaint with the Commission, or participated as a witness in an anti-discrimination agency proceeding?

ADVERSE ACTION:

Note: The Sioux Falls Human Relations Commission only has jurisdiction over events that have occurred within the last 180 days.

What did the person you are complaining against do because of your membership in a protected class as identified above? Check all that apply.

PART 3: RESPONDENT INFORMATION

This section is to provide the Human Relations Commission with information on the person or organization you are alleging has discriminated against you. This person/organization will receive a copy of your formal complaint when filed.

Note: If you are filing against more than one organization, you will need to file a separate complaint for each organization.

ADDRESS WHERE ALLEGED DISCRIMINATION TOOK PLACE:

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

NAMES OF PERSON(S) WHO DISCRIMINATED AGAINST YOU:

This section asks you to identify the specific individual(s) who was involved in the discriminatory acts. Provide the full legal name and contact information for the individual(s) who discriminated against you.

If you are alleging harassment, please list the name(s) and position(s) of the individual(s) who harassed you, as well as the dates and locations of the harassment.

If you are claiming harassment, who harassed you?

PART 4: ALLEGATIONS

This section asks you to provide information about your allegations of discrimination by the organization and/or individuals you are filing against. If you have any documents or correspondence between yourself and the person you are filing against that may support the claims you allege in this section, you may provide copies to our office.

SUMMARY OF ALLEGATIONS:

These questions aim to understand the circumstances around your claim and establish a connection between your protected class and the adverse action taken against you. The information provided in this section will form the basic claims within a formal complaint if filed.

Please be sure to address each adverse action identified above and ensure that your responses reflect the protected class(es) you previously identified as being the reason you were discriminated against in Part 3.

Are you aware of other individuals who were treated Are you aware of other individuals who were treated better than you under the same or similar circumstances?

Are you aware of other individuals who were treated the same as or worse than you Are you aware of other individuals who where treated the same as or worse than you under the same or similar circumstances?

Did you ever complain of discriminatory treatment?

WITNESSES:

This section asks for information on any individuals who could support your claim during a potential investigation. Please provide the name and contact information of any potential witnesses as well as what information they could provide the Commission.

List any and all persons who witnessed the discrimination and can provide support to your allegations.

RESPONDENT’S STATED REASON(S) FOR ACTION(S):

If the Respondent gave you a non-discriminatory reason or explanation for the discriminatory actions you are claiming, please describe them in this section.

PART 5: FILING INFORMATION

Because the Sioux Falls Human Relations Commission shares jurisdiction over certain areas with other government agencies, it is important for you to provide any information on claims that have already been filed elsewhere to ensure efficient processing.

Have you filed similar complaints with any other local, state, or federal governmental agency? (i.e., South Dakota Division of Human Rights)

RELIEF:

The Human Relations Commission has limited authority to grant relief under Chapter 98. The goal of the Commission is to make any person who has suffered discrimination “whole”. Making whole means to put the person who has been discriminated against in the position they would have been had the discrimination not occurred. This may include compensatory damages such as repayment of out-of-pocket expenses caused by the discrimination. The Commission does not have the authority to award punitive or emotional damages for pain and suffering.

If both parties agree, the Human Relations Office supports and facilitates mediation to reach an informal resolution to the dispute as an alternative to the investigative fact-finding and decision-making process.

Would you be willing to participate in mediation to seek an early resolution of your claim as an alternative to the investigative and 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 participate in 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.

PART 6: VERIFICATION:

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

Important:
Your signature on the complaint form is required. The complaint will not be processed until a signature is provided.

I certify by checking this box I intend to file a charge of discrimination, and I authorize the Sioux Falls Human Relations Commission to investigate the discrimination described above. I understand that the Sioux Falls Human Relations Commission must give the Respondent 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, sex, national origin, religion, color, disability, familial status, creed, ancestry, or retaliation.I declare and affirm that this information is, to the best of my knowledge, true and correct.