Universal Paid Leave Amendment Act (UPL)

Employment Intake Questionnaire (Updated June 5, 2024)

The Universal Paid Family Leave Amendment Act of 2016 (“UPL”) was passed by the D.C. Council in 2016. Despite its

name, UPL does not provide leave. Rather, it allows eligible private-sector employees in the District to receive pay

for certain qualifying leave for family or medical purposes. For example, an employee eligible to take leave under

the D.C. Family and Medical Leave Act may get paid during the leave under UPL. This benefit does NOT apply to

District government employees. Certain eligibility requirements apply, and only certain types of leave qualify for

UPL. The Department of Employment Services (“DOES”) administers UPL, including making eligibility and award

determinations. The Office of Human Rights (“OHR”) accepts UPL complaints other than claim determinations, such

as complaints of interference or retaliation because an individual sought UPL benefits. Before filling out this

complaint form, prospective complainants should review more information about this law located at

ohr.dc.gov/page/universalpaidleave.

Instructions

Complete this form ONLY if you believe a private sector employer has interfered with your right to the benefits

provided under the UPL or if you believe that a private sector employer has retaliated against you for requesting,

applying for, or using paid leave under the UPL. If you are a D.C. government employee who wishes to file a

complaint based on your application for Paid Family Leave (PFL), you should file your complaint with the D.C.

Department of Human Resources (DCHR).

If you believe you have been discriminated against based on a protected basis in addition to a violation of the

UPL, please also fill out OHR’s Human Rights Act Employment Form at ohr.dc.gov/service/file-discrimination-

complaint.

All fields are required unless otherwise indicated.

Jurisdiction

OHR needs to understand where and when the alleged violations occurred. Please check the appropriate boxes.

Do you work for a private sector employer (not for the District of Columbia government or the federal government)?

Yes No

Do you spend at least 50 percent of your time physically working in the District of Columbia?

Yes No

Did the alleged violation(s) occur within the past year?

Yes No

If yes, when did the alleged violation(s) occur? (Cases must be brought to OHR within one year.)

Have you filed the same or similar complaint in the D.C. Superior Court or any other courts?

Yes No

If yes, please provide the case number and date of when you filed the complaint with the D.C. Superior

Court or any other court.

Hav

e you filed a related complaint with the United States Equal Employment Opportunity Commission (EEOC)?

Yes No

✔

If yes, please provide the case number and date of when you filed with the EEOC.

Complainant Information

Complainant’s Preferred Name

Complainant’s Address

mplainant’s Preferred Telephone Number

Complainant’s Email Address

Do you need reasonable accommodation?

Yes No

If yes, please explain here:

What are your pronouns? (write below)

What language do you prefer to communicate in?

English Amharic Chinese French Korean Spanish Vietnamese

Other:

Attorney or Counsel Information

(Note: You are not required to have an attorney, but if you have one, please fill out the below)

Counsel’s Name

Counsel’s Address

Counsel’s Telephone Number:

unsel’s Fax Number (optional)

Counsel’s Email Address

Respondent Information

Name of Company or Organization

Name of Title of Principle Officer (e.g. owner or manager)

Company or Organization Address

Telephone Number:

Fax Number (optional)

Email Address of Principle Officer

Incident Information

The following questions help us to ensure we have proper information about your UPL experience and assist us in preparing

for our intake interview with you. Please complete each step below to the best of your ability before submitting this

complaint.

Applying for Universal Paid Leave (UPL)

Did you apply with the D.C. Department of Employment Services (DOES) for UPL leave? (If you have not applied for

UPL leave with DOES, you may apply with DOES to obtain UPL leave.)

Yes

Date you applied for UPL leave:

Date(s) you requested to be on UPL leave:

id DOES approve your application for UPL leave?

Yes

Date DOES approved your UPL application:

Date(s) DOES approved for you to be on UPL leave:

Notice or Poster on Information and Rights: At the time you sought to obtain paid family or medical leave from your

employer, did your employer provide you with any information about UPL, such as eligibility criteria?

Yes No Unsure

If yes, was this provided by your employer or was there a UPL poster posted at your workplace?:

UPL Interference

Do you allege that your employer interfered with your ability to apply for or take UPL leave?

Yes No

If yes, how do you believe that your

employer interfered with your ability to apply for or take UPL leave?

Please provide a detailed statement of the incident(s) that led you to believe your employer was interfering

with your UPL leave, including relevant dates and the name(s) and job title(s) of the person(s) who were

involved.

ere you able to take UPL leave on the days you applied for and/or were approved to take UPL leave?

Yes No

If no, please explain:

UPL Retaliation

Do you allege that your employer retaliate against you for taking UPL leave?

Yes No

If yes, what actions did your employer take that you believe were in retaliation against you for

taking UPL leave?

ntimidation, threats, or harassment Discharge Discipline Suspension

Transfer or assignment to a lesser position in terms of job classification or job security

Reduction in pay or hours or denial of additional hours

Informed another employer that you applied for and/or took UPL

Reported, or threated to report, you or your family member’s actual or suspected citizenship or

immigration status to a federal, state, or local agency

ther:

If yes, how do you believe your employer retaliated against you for applying for or taking UPL leave? Please provide a

detailed statement of the incident(s) that led you to believe your employer was retaliating against you for applying for

or taking UPL leave, including relevant dates and the name(s) and job title(s) of the person(s) who were involved:

Possible Related Claim: DC Family and Medical Leave Act (DCFMLA)

Did you apply for DCFMLA leave with your employer as well as UPL leave?

Yes No

If no, did you notify your employer that you needed to take leave for your own serious medical condition, your

family member’s serious medical condition, or for bonding with a child? Please provide details:

Notice or Poster on Information and Rights: At the time you sought to obtain family or medical leave from your

employer, did your employer provide you with any information about the DCFMLA, such as eligibility criteria?

Yes No Unsure

If yes, was this provided by your employer or was there a DCFMLA poster posted at your workplace?

ave you been employed by your employer for at least 12 total months (does not need to be consecutive) over the

past 7 years?

Yes No (If no, you are not yet eligible for DCFMLA leave.)

During these last 12 months you have worked for your employer, did you work at least 1000 total hours?

Yes No (If no, you are not yet eligible for DCFMLA leave.)

Did your employer have at least 20 employees at the time you requested DCFMLA leave?

Yes No (If no, your employer did not have enough employees for you to be covered by the DCFMLA.)

Had you taken DCFMLA leave in the 24-month period immediately preceding the requested leave?

Yes No

If yes, how many weeks of DCFMLA leave did you take in the 24-month period immediately preceding the

requested leave?

id your employer approve your application for DCFMLA leave?

Yes No

If no, please explain how and when your employer denied your application for DCFMLA leave. Include relevant

date(s) and the name(s) and job title(s) of the person(s) who denied your application for DCFMLA leave:

Do you allege that your employer interfered with your ability to apply for or take DCFMLA leave?

Yes No

If yes, please explain how and when you believe your employer interfered with your ability to apply for or take

DCFMLA leave. Include relevant date(s) and the name(s) and job title(s) of the person(s) you believe interfered

with your ability to apply for or take DCFMLA leave:

o you allege that your employer retaliated against you for applying for or taking DCFMLA leave?

Yes No

If yes, please explain how and when you believe your employer retaliated against you for applying for or taking

DCFMLA leave. Include relevant date(s) and the name(s) and job title(s) of the person(s) you believe retaliated

against you for applying for or taking DCFMLA leave, as well as what actions the person(s) took that you believed

were retaliatory:

Additional Information

Please describe any additional relevant information.

Witnesses

List whom you feel can corroborate your experience and provide evidence in your support:

Witness One

Name:

Phone number:

Email address:

Witness Two

Name:

Phone number:

Email address:

Acknowledgement

want to file a charge of interference and/or retaliation, and I authorize OHR to investigate the allegations

described above.

understand that OHR must give the employer I accuse of the allegations described above information about

the charge, including my name.

acknowledge that OHR also will investigate additional claims under other civil rights laws in the District of

Columbia, if applicable.

I agree to cooperate with OHR’s processes and to treat OHR’s employees in a respectful manner. I

understand that failure to do so may lead to dismissal of my complaint.

Complainant’s Signature: Today’s Date:

Please return this form by mail or in-person to 441 4th Street NW, Suite 570N, Washington DC, 20001 or by email to

ohr.i[email protected].