Language
English (US)
Spanish (Latin America)
Vietnamese
Portuguese (Brazil)
LLAC Hotline Intake Form
Thank you for taking the time to contribute to community data, make a complaint and request resources! This is not an official report. ALL INFORMATION IS CONFIDENTIAL. Please include as much detail as possible. You may leave out your name if you would like to remain anonymous.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Mode of Communication
Phone Call
WhatsApp
Text
Email
This complaint is for
*
Me
My family or friend
On behalf of a client or community member
Preferred spoken language
*
Spanish
Vietnamese
Haitian Creole
Portuguese
Arabic
Other
Preferred written language
*
Spanish
Vietnamese
Haitian Creole
Portuguese
Arabic
Other
Parish (where you live)
*
East Baton Rouge
Jefferon Parish
Lafourche Parish
Orleans Parish
Plaquemines Parish
St Bernard Parish
St Charles Parish
St Tammany
West Baton Rouge
Other
Why are you contacting LLAC today?
*
My language access rights have been violated and I want to tell LLAC about it
I would like to better understand language access rights
I'm looking for resources in my community that speak my language
If you are filling out this form online, would you like a LLAC volunteer to contact you?
*
Yes, I would like to talk to someone at LLAC
No, I just want to document my experience
Back
Next
Language Access Complaint
Where were you when you were denied or could not access language services?
Education Setting (school, daycare, etc.)
Healthcare Setting (hospital, clinic, etc.)
Justice System Setting (court, police, law enforcement, etc.)
Government Office (city offices, OMV, SSA)
Where did this incident take place? (Name of Institution)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When did it happen?
-
Month
-
Day
Year
Date Picker Icon
Please describe in detail what occurred. (Include dates and times, whether this was one or multiple occurrences, if there were any witnesses, who specifically did not provide interpretation or translation, what did they say to you)
Were you told you had to bring your own interpreter?
Yes
No
If you brought an interpreter, did they charge you a fee?
Yes
No
Have you brought this concern to any other authority, advocate, or organization? If yes, to whom and what steps were taken?
Would you like a representative from LLAC to contact you to support you in making a report or other advocacy?
Yes
No
Back
Next
More Information and Resources
Do you know what your Title 6 language access rights are?
*
Yes
No
Maybe
Is there a specific area of language access rights that you are interested in learning more about?
Health
Education
Justice System
Government
What kind of resources are you looking for in your community?
Health care
Education
Legal
Government
Other
How would you prefer to receive these resources from LLAC?
Text Message
WhatsApp
Email
Phone Call
Back
Next
Follow up & Feedback
How did you hear about the Louisiana Language Access Hotline?
*
Friend or family member
Work
Attorney
Social worker
Educator
Organizer
Facebook
Instagram
Flyer
Other
Organization
Is it ok if a volunteer contacts you in a couple of weeks to follow up on the resources we have provided?
*
Yes
No
We are hoping to include community members in our data collection and advocacy efforts. Would you be interested in learning about ways you could be involved in the LLAC hotline or other initiatives and campaigns?
*
Yes
No
Maybe
Would you like to receive a copy of your responses by email?
*
Yes
No
Submit
Should be Empty: