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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.

Applicants 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 support Store
Education & training Theatre
Police services Insurance
Medical/health services Public transportation
Sporting or other recreational facility Government, please describe: __________________
Retail 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.

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.

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?

C5 Was there an investigation? Yes No (Go to Part II)

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

30/06/08 Form 1-C Page 1 of 5


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.

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

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.

C9 Do you have particular needs related to your disability? Yes 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? Yes 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.

C11 Did the Respondent(s) try to meet your needs? Yes No (Go to C12) 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?

30/06/08 Form 1-C Page 2 of 5


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

C12 Do you plan to submit medical reports or documents Yes No


related to your particular needs at the hearing?
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.

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 Yes No


pregnancy?

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

30/06/08 Form 1-C Page 3 of 5


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?

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.

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.

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.

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.

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
30/06/08 Form 1-C Page 4 of 5
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:


I claimed or enforced my rights under the Code (Go to C29)
I refused to infringe on another person's rights under the Code (Go to C29)
I started or took part in a human rights proceeding (Go to C28)

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 #: ___________________
The Human Rights Tribunal Of Ontario (HRTO) HRTO File #: ___________________
Other Proceeding specify:

C29 Please explain why you believe you were reprised against.

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