Non-Discrimination and Title VI Complaint Form

Non-Discrimination, ADA and Title VI Complaint Form

This is where you can file a Non-Discrimination, ADA or Title VI Complaint.

Name (Complainant)*
Please enter your name
First Last
Phone #*
Please enter a good contact number for you.
Home Address*
Please enter your home address, city state and zip.

Street Address Address Line 2 City State ZIP Code
If Applicable, name of persons who allegedly discriminated against you
Please list the name of person(s) who allegedly discriminated against you.
Basis of Non-Discrimination and/or Title VI Action(s) (Check all that might apply)
Non-Discrimination:
Basis of Non-Discrimination Action(s) (Check all that might apply)
- Sex
- Age
- Disability
Title VI:
Basis of Title VI Action(s) (Check all that might apply)
- Race
- Color
- National Origin
Date of Alleged Incident:*
MM slash DD slash YYYY
Location and position of person(s) who alleged discrimination against you if known:
Please list the location and position of person(s) who alleged discrimination against you (if known):
Explain Briefly and clearly as possible what happened and how you believe you were discriminated against. Indicate who whas involved. Be sure to include how you feel other persons were treated differently than you. Please attach any additional material about your complaint.*
Explain Briefly and clearly as possible what happened.
Additional information
Please upload any additional information relevant to your complaint.
Max. file size: 50 MB.
Why do you believe these events occurred?*
Please explain why do you believe these events occurred?
What other information do you think is relevant to this complaint?*
Please list any other relevant information.
How can this issue be resolved to your satisfaction?*
Please list how this issue can be resolved to your satisfaction?
Please list the names, addresses, phone numbers and job titles of the person(s) we may contact for additional information about your complaint (witnesses, fellow employees, supervisors, others):
Please list additional people we can contact about your complaint.
Your Email Address
Please enter your emails address
CAPTCHA
I Agree*
In submitting this form, you agree you understand the policy and procedures for the ADA/Nondiscrimination/Title VI will be followed. Additionally, you attest that the information you provided is true and correct as you know it.
Comments
This field is for validation purposes and should be left unchanged.

Non-Discrimination, ADA and Title VI Complaint Form

Basis of Non-Discrimination and/or Title VI Action(s) (Check all that might apply)

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