Form 0112 - Title Iv-Compliant Form Page 2
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2MDOT 0112 (01/17)
Page 2 of 2
Alleged discrimination:
Complaints should be filed within 180 days of the alleged discrimination. If you could not reasonably be expected to
know the act was discriminatory within the 180 day period, you have 60 days after you became aware to file your
complaint.
If your complaint is in regard to discrimination in the delivery of services or discrimination that involved the treatment
of you or others by the agency or department indicated above, please indicate below the basis on which you believe
these discriminatory actions were taken. (Check all that apply)
If you believe that you were discriminated against because you are African American, you
Example:
would mark the box labeled Race or Color and write African American in the space provided.
Example: If you believe the discrimination occurred because you are female, you would mark the box
labeled sex and write female in the space provided.
Disability
Race
:
Sex
:
:
Religion
Income
Color
:
:
:
Age
National origin
Retaliation
:
:
:
Explain:
Please explain as clearly as possible what happened. Provide the name(s) of witness(es) and others involved in the
alleged discrimination. (Attach additional sheets if necessary and provide a copy of written materials pertaining to
your case.)
SIGNATURE
DATE
Note: The laws enforced by this department prohibit retaliation or intimidation against anyone because that individual
has either taken action or participated in action to secure rights protected by these laws. If you experience retaliation
or intimidation separate from the discrimination alleged in this complaint or if you have questions regarding the
completion of this form, please contact:
MDOT, EEO Officer/Title VI Coordinator
Michigan Department of Transportation
425 W. Ottawa Street
Lansing, MI 48909
Phone: 517-373-0980
Fax: 517-373-2687
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