Please provide the name of an individual at a different address in your
local area who would know how to reach you:
Provide the name, address and telephone number of the public entity/place
of public accommodation (establishment which serves the public) that you
believe discriminated against you.
*What was the most recent date your alleged harm took place? (mm/dd/yyyy):
*What action was taken against you that you believe to be
*State briefly: Why do you believe this action was taken against you? It is a violation of the law to deny you your rights for any of the following bases: Race, Color, National Origin, Sex, Religion, Sexual Orientation, Gender Identity/Expression, Age, Disability, Marital Status, Familial Status (families with children under 18) or Retaliation.
State briefly: What reason, if any, was given for the alleged act of discrimination?
Normally, your identity as a Complainant will be disclosed to the organization which allegedly discriminated against you.
Have you sought assistance about the action you think was discriminatory
from any agency, an attorney, the Florida Commission on Human Relations
(FCHR) or from any other source?
Name of Assistance Source:
Result if Any:
Have you filed a public accommodations complaint in the past with the Tampa
Office of Human Rights or FCHR?
Approximate Date Filed:
Charge Number (if known):
PRIVACY ACT STATEMENT: This form is covered by the Privacy Act of 1974;
Public Law 93-579 Filling out and bring or sending us this questionnaire does not mean that
you have filed a charge. Once you have submitted the
completed form, you will be contacted by our office within 10 days. If you
are not contacted in 10 days please call (813) 274-5835. Please be
advised that there are time limits to file a charge, generally within 180 days
or in some jurisdictions one (1) year of the alleged harm.
Office Mailing Address: 306 E. Jackson Street, 3N , Tampa, Florida, 33602
If you need an accommodation under the Americans with Disabilities Act to
complete the questionnaire, please call (813) 274-5835
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