NAME & CONTACT INFORMATION

Maryland Commission on Civil Rights Preliminary Questionnaire (PQ)

Please answer all questions as completely and accurately as possible. Fields marked with an asterisk (*) are required for completion. This Preliminary Questionnaire (PQ) takes approximately 20 minutes to complete. You cannot save your progress and return to it later - the PQ will time out after 15 minutes of inactivity and clear any information you entered. You can navigate and review your responses using the BACK and NEXT buttons located at the bottom of each page.

	1. Complainant Personal Information (Person Filing Complaint)

	First Name:*

	MI:

	Last Name:*

Street or Mailing Address:*

		Street		City		County		State		Zip

Phone Number:*
Please enter at least 1 phone number at which you can be reached.

		XXX-XXX-XXXX
Home
Work
Cell

	Email Address:*

	Date of Birth:* mm/dd/yyyy

Sex:*

What is your race?*

Black or African American

Asian

Native American

Hispanic or LatinX

Other, please specify

	What is your National Origin?* This is your country of origin or ancestry.

	Please answer each of the next three questions.

Do you have a disability?*

Yes

	Do you need an accommodation or a translator to use MCCR's services? If so, please specify: Examples include an ASL Interpreter or a Spanish Translator.

	Please Provide The Name Of A Person We Can Contact If We Are Unable To Reach You. If MCCR is unable to reach you at any point during the intake and investigation processes, your complaint may be administratively closed.

	Name:*

	Relationship:*

Street or Mailing Address:*

		Street		City		County		State		Zip

Phone Number:*
Please enter at least 1 phone number at which you can be reached.

		XXX-XXX-XXXX
Home
Work
Cell

Have you sought help about this situation from an attorney, a union, or any other source?*

Yes

If yes, please provide the name of the organization, the name of person you spoke with, date(s) of contact, and results (if any).