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State Form Number (SFN) 52974

Human Rights Discrimination Intake Questionnaire

Instructions for SFN 52974

If you believe that you have been unlawfully discriminated against in the provision of a public accommodation (see (N.D.C.C. Chapter 14-02.4-02 (14)), public service (see (N.D.C.C. Chapter 14-02.4-02 (15)), or credit transaction, and would like the North Dakota Department of Labor and Human Rights' assistance, you may complete and return the Human Rights Intake Questionnaire. The intake questionnaire provides the department with information to determine if your concerns fall within the scope of our authority. The department is able to accept complaints of unlawful discrimination in these areas based on race, color, religion, sex, disability, age, national origin, marital status, or receipt of public assistance. This means actions that are "because of" one or more these factors can be addressed.

Please answer the items on the questionnaire completely and specifically so that we can fully assess your situation. Please type or write your answers legibly, using additional paper if necessary. Incomplete questionnaires will be returned for completion. Copies of any records or documents you have that support your claim should also be submitted with the completed questionnaire.

If the department determines that it does have a legal basis to proceed, it will generate a formal complaint, which will be mailed to you. You will be asked to review the complaint, sign it, and return it to the Department of Labor and Human Rights.

If the department determines that it does not have a legal basis to proceed, you will be notified in writing and given the opportunity to provide further information if available. Please be advised that there are many acts that may seem unfair that do not constitute unlawful housing discrimination.

Timeliness is important when filing your concerns. There is a 180-day time limitation, from the date of the alleged discriminatory act, within which the signed formal complaint must be returned to the department for complaints alleging discrimination in public accommodations or public services. The time limitation for complaints alleging discrimination in credit transactions is 300 days. Keep in mind that the intake questionnaire must be submitted in time to allow the department to assess the initial information, acquire any additional information necessary, and process a formal complaint before the applicable time limit expires.

  • 600 East Boulevard Ave
  • Dept 406
  • Bismarck ND 58505-0340
  • (701) 328-2660
  • 1-800-582-8032 - In-state toll-free
  • 1-800-366-6888 or 1-800-366-6889 - TTY (Relay ND)
  • (701) 328-2031 Fax