Discrimination Complaint Form (Page 3 of 4) in pdf

Discrimination Complaint Form Page 3

Discrimination Complaint Form

Section I:

Name:

Address:

Telephone (Home):

Telephone (Work):

Electronic Mail Address:

☐ Large Print

☐ Audio Tape

Accessible Format Requirements?

☐ TDD

☐ Other

Section II:

☐Yes*

☐No

Are you filing this complaint on your own behalf?

*If you answered “yes” to this question, go to Section III.

If not, please supply the name and relationship

of the person for whom you are complaining.

Please explain why you have filed for a third party:

Please confirm that you have obtained the permission of the

☐Yes

☐No

aggrieved party if you are filing on behalf of a third party.

Section III:

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

☐ Race

☐ Color

☐ National Origin

☐ 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. 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 this form.

Section VI:

☐Yes

☐No

Have you previously filed a Title VI complaint with this agency?

If yes, please provide any reference information regarding your previous complaint.

Section V:

Discrimination Complaint Form Page 3