Free Human Rights Assessment Questionnaire

Human Rights Case Assessment Questionnaire

Please provide details about your experience related to potential unfair treatment under human rights laws.
Name

First NameLast Name
Address

Street Address

CityProvincePostal Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Part 1: Identifying the Protected Ground
Do you believe you were treated unfairly because of a personal characteristic?
Which personal characteristic(s) do you believe were involved?

Other
If disability is involved, is it a physical condition, a mental health condition, or both?
Part 2: Identifying the Adverse Impact (The Social Area)
What setting did the incident happen in?
What specific negative outcome did you experience?

Other
Did this result in a financial loss or a negative impact on your health or dignity?
Part 3: Proving the Link (The Connection)
Why do you believe your [Characteristic] was a reason for the treatment you received? It does not need to be the only reason.
Did anyone make comments or take actions that directly referenced your [Characteristic]? If yes, please describe.
Were others in a similar situation who did not have your [Characteristic] treated differently?
Part 4: Timelines & Jurisdiction
When did the last incident occur?

MonthDayYear
Date
Have you already filed a claim elsewhere for the same issue?
Was the employer a federally regulated organization?
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Human Rights Case Assessment Questionnaire