Title VI Complaint Form

Title VI Complain Form
Please fill out this form as thoroughly as possible. We will use the information from this form to investigate your Title VI complaint. Rachel Burch, Human Resources Director, is the agency's Title VI complaint officer. You may call her at 615-890-4389, Monday through Friday, between 8 a.m. and 4:30 p.m. with any questions. Email her at rachel.burch@journeystn.org for the quickest response.
Name of Complainant (Person filing this complaint form)*

First NameLast Name
Email Address of Complainant (We may use this email to contact you)*
example@gmail.com
Phone Number of Complainant (We may use this email to contact you)*
Please enter a valid phone number.
Date of alleged Title VI violation (If you recall -- not required)

MonthDayYear
Date
Today's Date and Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Please use the space below to describe the Title VI violation. Include as many details as possible. *
Should be Empty:

Title VI Complain Form