Civil Rights Complaint Form printable pdf download

Title VI / Civil Rights Complaint Form

Section 1

Name:

Address:____________________________________

_________________________

_______ ___________

Street Address

City

State

Zip Code

Telephone (Home): _____________________________ Telephone (Alternate): _______________________

Electronic Mail Address:

If you require accessible format(s), please check the appropriate box(s):

 Large Print

 Audio Tape TDD

Other, please specify ______________________________________

Section 2

Are you filing this complaint on your own? Yes (If yes, Go to Section 3) No (If no, go to next line)

Please provide the name and address of the person who alleges discrimination:

Name: __________________________________________

Address:____________________________________

_________________________

_______ ___________

Street Address

City

State

Zip Code

Please explain why you are filing this claim for a third party:

Please confirm that you have obtained permission. Yes No

Section 3

I believe that the discrimination experienced was based on (check all that apply):

Race

Color

National Origin (includes Limited English Proficiency)

Disability

Date of alleged discrimination (Month, Day, Year): __________________________

Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all

persons who were involved and include the name and contact information of the person(s) who discriminated

against you (if known) as well as names and contact information of any witnesses. If more space is needed, please

use the back of the form or another sheet of paper.

__________________________________________________________________________________________

_____________________________________________________________________________________________

Section 4

Have you previously filed a complaint with Capital Area Transit (CAT)? Yes No

Section 5

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

Yes No If yes, check all that apply and provide the name of the agency or court:  Federal

Agency: __________  Federal Court: ________________

 State Agency: __________________

 State Court: _________________  Local Agency: _________________

Please provide information about a contact person at the agency/court where the complaint was filed.

Name: __________________________________________

Title: _______________________________________

Agency: _________________________________________

Telephone Number: __________________________

Address: ______________________________________________________________________________________

Section 6

You may attach any written materials or other information that you think is relevant to your complaint.

I affirm that I have read the above and that it is true to the best of my knowledge, information and belief.

Signature and date required.

______________________________________________________

___________________

Complainant’s Signature

Date

Please submit this form and any additional materials in person or mail to: Title VI Coordinator, Human Resources

Department, Capital Area Transit, 901 N. Cameron Street, Harrisburg, Pennsylvania 17101

Si se necesita información en otro idioma, por favor llame al

(717-233-5657).

Capital Area Transit’s use only: Date Received: _______________ Person receiving complaint: ______________________________________

Civil Rights Complaint Form

Related Articles

Related forms

Related Categories