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Human Rights Tribunal of Ontario Application to the Human Rights Tribunal of Ontario Area of

Human Rights Tribunal of Ontario

Application to the Human Rights Tribunal of Ontario Area of Discrimination: Goods, Services and Facilities (Form 1-C)

Note: Complete this form if you believe you were discriminated against in the area of Goods, Services and Facilities. Attach this form to your Application.

Applicant’s Name:

Respondent(s) Name(s):

Applicant’s Name: Respondent(s) Name(s):
Applicant’s Name: Respondent(s) Name(s):
Applicant’s Name: Respondent(s) Name(s):
Applicant’s Name: Respondent(s) Name(s):

PART I

Questions About the Service, Good or Facility

C1 Put an "X" beside the point that best describes the service, good or facility that this Application is based on.

Income supportgood or facility that this Applicat ion is based on. Education & training Police services Medical/health

Education & trainingfacility that this Applicat ion is based on. Income support Police services Medical/health services Sporting or

Police servicesion is based on. Income support Education & training Medical/health services Sporting or other recreational

Medical/health serviceson. Income support Education & training Police services Sporting or other recreational facility Retail Store Theatre

Sporting or other recreational facility& training Police services Medical/health services Retail Store Theatre Insurance Public transportation

services Sporting or other recreational facility Retail Store Theatre Insurance Public transportation

Retail

Storeservices Sporting or other recreational facility Retail Theatre Insurance Public transportation Government, please

TheatreSporting or other recreational facility Retail Store Insurance Public transportation Government, please describe:

InsuranceSporting or other recreational facility Retail Store Theatre Public transportation Government, please describe: Other,

Public transportationother recreational facility Retail Store Theatre Insurance Government, please describe: Other, please describe: C2

Government, please describe:Retail Store Theatre Insurance Public transportation Other, please describe: C2 Complete this section only if

Insurance Public transportation Government, please describe: Other, please describe: C2 Complete this section only if

Other, please describe:

C2 Complete this section only if your Application is about a practice or policy.

Tell us what is the practice or policy you are complaining about and explain how it relates to equal treatment with respect to services, goods and facilities.

you are complaining about and explain how it relates to equal treatment with respect to services,

C3 Complete this section only if your Application is about a law.

Tell us what is the law you are complaining about and explain how it relates to equal treatment with respect to services, goods and facilities.

you are complaining about and explain how it relates to equal treatment with respect to services,

Questions About Complaining to Someone in Authority

Complete this section only if you complained to someone in authority about the alleged discrimination.

C4 To whom did you complain?

section only if you complained to so meone in authority about the alleged discrimination. C4 To
alleged discrimination. C4 To whom did you complain? C5 Was there an investigation? Yes No (Go

C5 Was there an investigation?

Yes

whom did you complain? C5 Was there an investigation? Yes No (Go to Part II) a)

No (Go to Part II)

a) If you answered “Yes” to C5, what was the outcome of the investigation?

Human Rights Tribunal of Ontario Application to the Human Rights Tribunal of Ontario Area of

Human Rights Tribunal of Ontario

Application to the Human Rights Tribunal of Ontario Area of Discrimination: Goods, Services and Facilities (Form 1-C)

PART II

The following Part asks you to answer how you believe you were discriminated against based on grounds you identified. If you believe that you were discriminated against based on more than one ground, fill out all the sections that apply.

Questions About Discrimination on the Grounds of Race, Colour, Ancestry, Place of Origin, Citizenship, or Ethnic Origin

Complete this section only if you believe that you have been discriminated against on one or more of these grounds:

race, colour, ancestry, place of origin, citizenship, or ethnic origin.

C6 Explain why you believe you were discriminated against because of your race, colour, ancestry, place of origin, citizenship, or ethnic origin.

you were discriminated against because of your race, colour , ancestry, place of origin, citizenship, or

C7 Please describe how you identify yourself in terms of your race, colour, ancestry, place of origin, citizenship, and ethnic origin.

ancest ry, place of origin, citizenship, and ethnic origin. Questions About Discrimination on the Ground of

Questions About Discrimination on the Ground of Disability or Perceived Disability

Complete this section only if you believe that you have been discriminated against on the ground of disability or perceived disability.

C8 Explain why you believe you were discriminated against based on your disability or a perceived disability.

C8 Explain why you believe you were discriminated a gainst based on your disability or a

C9 Do you have particular needs related to your disability?

C9 Do you have particular needs related to your disability? Yes No (Go to C12)

Yes

C9 Do you have particular needs related to your disability? Yes No (Go to C12)

No (Go to C12)

a)

If you answered “Yes” to C9, describe your particular needs.

 

C10 Did you ask the Respondent(s) to meet your needs?

C10 Did you ask the Respondent (s) to meet your needs? Yes No (Go to C12)

Yes

C10 Did you ask the Respondent (s) to meet your needs? Yes No (Go to C12)

No (Go to C12)

a)

If you answered “Yes” to C10, describe what you asked the Respondent(s) to do. If you named more than one Respondent, please tell us who you spoke to.

more than one Respondent, please tell us who you spoke to. C11 Did the Respondent(s) try

C11 Did the Respondent(s) try to meet your needs?

Yes

to. C11 Did the Respondent(s) try to meet your needs? Yes No (Go to C12) Don't

No (Go to C12)

the Respondent(s) try to meet your needs? Yes No (Go to C12) Don't Know (Go to

Don't Know (Go to C12)

a) If you answered “Yes” to C11, describe what the Respondent(s)’ did to meet your needs. If you named more than one Respondent, please tell us what each did.

b) If you answered "Yes" to C11, why do you believe the Respondent(s) efforts to meet your needs were not enough?

If you answered "Yes" to C11, why do you believe the Re spondent(s) efforts to meet
Human Rights Tribunal of Ontario Application to the Human Rights Tribunal of Ontario Area of

Human Rights Tribunal of Ontario

Application to the Human Rights Tribunal of Ontario Area of Discrimination: Goods, Services and Facilities (Form 1-C)

Questions About Discrimination on the Ground of Disability or Perceived Disability

on the Ground of Disability or Perceived Disability C12 Do you plan to submit medical reports

C12 Do you plan to submit medical reports or documents related to your particular needs at the hearing?

Yes

related to your particular needs at the hearing? Yes No a) If you answered “Yes” to

No

a) If you answered “Yes” to C12, please list the medical reports or documents here. You do not need to send copies at this time.

Questions About Discrimination on the Ground of Creed (Faith, Religion or System of Beliefs)

Complete this section only if you believe that you have been harassed or discriminated against on the ground of creed (faith, religion or system of beliefs).

C13 Explain why you believe you were discriminated against based on your creed.

C13 Explain why you believe you were discriminated against based on your creed.

C14 Please describe your creed.

C14 Please describe your creed.

Questions About Discrimination on the Grounds of Sex, Pregnancy, or Gender Identity

Complete this section only if you believe that you have been discriminated against on the grounds of sex, pregnancy, or gender identity.

C15 Is your Application about discrimination on the ground of pregnancy?

C15 Is your Application about discrimination on the ground of pregnancy? Yes No

Yes

C15 Is your Application about discrimination on the ground of pregnancy? Yes No

No

C16 Explain why you believe you were discriminated against based on your sex, pregnancy, or gender identity.

C16 Explain why you believe you were discriminated agains t based on your sex, pregnancy, or

C17 Please identify your sex or describe your gender identity.

C17 Please identify your sex or describe your gender identity.

Questions About Discrimination on the Ground of Sexual Solicitation, Sexual Advances or Reprisal for Refusing a Sexual Solicitation or Advance

Complete this section only if you believe that you have experienced sexual advances or sexual solicitation or reprisal for refusing a sexual solicitation or advance from someone who is in a position to grant or deny you a benefit.

C18 Tell us what happened.

C18 Tell us what happened.
Human Rights Tribunal of Ontario Application to the Human Rights Tribunal of Ontario Area of

Human Rights Tribunal of Ontario

Application to the Human Rights Tribunal of Ontario Area of Discrimination: Goods, Services and Facilities (Form 1-C)

C19 How was this person in a position to grant or deny a benefit?

Goods, Se rvices and Facilities (Form 1-C) C19 How was this person in a position to

Questions About Discrimination on the Ground of Sexual Orientation

Complete this section only if you believe that you have been discriminated against on the ground of sexual orientation.

C20 Explain why you believe you were discriminated against based on your sexual orientation.

C20 Explain why you believe you were discriminat ed against based on your sexual orientation.

C21 Please describe your sexual orientation.

C21 Please describe your sexual orientation.

Questions About Discrimination or Harassment on the Grounds of Family or Marital Status

Complete this section only if you believe that you have been discriminated against on the grounds of family or marital status.

C22 Explain why you believe you were discriminated against based on your family or marital status.

C22 Explain why you believe you were discriminated against based on your family or marital status.

C23 Please describe your family or marital status.

C23 Please describe your family or marital status.

Questions About Discrimination on the Ground of Age

Complete this section only if you believe that you have been harassed or discriminated against on the ground age.

C24 Explain why you believe you were harassed or discriminated against based on your age.

C24 Explain why you believe you were harassed or discriminated against based on your age.

C25 Please give your date of birth. (DD/MM/YYYY)

C25 Please give your date of birth. (DD/MM/YYYY)

Question About Harassment or Discrimination on the Ground of Association

Complete this section only if you believe that you were discriminated against because the Respondent(s) associated you with a person who is a member of a group identified in the Code.

C26 Please explain why you believe you were discriminated against because of association.

C26 Please explain why you believe you were discriminated against because of association.

Questions About Discrimination on the Ground of Reprisal

Complete this section only if you believe that the Respondent(s) have done something to punish you for exercising

Human Rights Tribunal of Ontario Application to the Human Rights Tribunal of Ontario Area of

Human Rights Tribunal of Ontario

Application to the Human Rights Tribunal of Ontario Area of Discrimination: Goods, Services and Facilities (Form 1-C)

your rights under the Ontario Human Rights Code.

C27

Put an "X" in each box that applies to you:

claimed or enforced my rights under the Code (Go to C29)C27 Put an "X" in each box that applies to you: refused to infringe on another

refused to infringe on another person's rights under the Code (Go to C29)claimed or enforced my rights under the Code (Go to C29) started or took part in

started or took part in a human rights proceeding (Go to C28)on another person's rights under the Code (Go to C29) I I I C28 If you

I

I

I

C28

If you marked that you started or took part in a human rights proceeding in C27, put an "X" in each box that applies to you and give any file number(s).

The Ontario Human Rights Commission (OHRC)OHRC File #:

OHRC File #:

The Human Rights Tribunal Of Ontario (HRTO)HRTO File #:

HRTO File #:

Other Proceeding – specify:The Human Rights Tribunal Of Ontario (HRTO) HRTO File #: C29 Please explain why you believe

C29 Please explain why you believe you were reprised against.

C29 Please explain why you believe you were reprised against.