Sioux Falls Human Relations Commission

Intake Questionnaire: Employment

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 Employment 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.

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.

This section is to provide the Human Relations Commission with necessary identifying and contact information. 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.

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.

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

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. If you believe you were treated differently because of your age, this form can be used to initiate an intake with the Equal Employment Opportunity Commission (EEOC).

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” is when an employer 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 work environment, supervisory practices, compensation, benefits, or other such matters.

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

Note: The Sioux Falls Human Relations Commission only has jurisdiction over events that have occurred within the last 180 days. If your claims are outside of this window, your complaint will be transferred to the EEOC.

What did the person you are complaining against do because of your membership in a protected class as identified in Part 3? Check all that apply.

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.

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. Unlawful harassment includes sexual and non-sexual harassment. Non-sexual harassment allegations most often lead to a hostile work environment claim. Hostile work environment refers to unwelcome conduct that is sufficiently pervasive or severe that it substantially alters the conditions of employment because of a protected characteristic.

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.

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 in Part 3 and ensure that your responses reflect the protected class(es) you previously identified as being the reason you were discriminated against in Part 3.

Please answer the following questions as they relate to your complaint. (REQUIRED)

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.

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

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.

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.

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