Discrimination Complaint Form

Discrimination Complaint Form

Title VI
Section I
Name*
Address*
Telephone (Home)*
Telephone (Work)
Electronic Mail Address:
example@example.com
Accessible Format Requirements?

Large PrintAudio TapeTDDOther
Section II
Are you filing this complaint on your own behalf?*

YesNo
If you answered no, 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 aggrieved party if you are filing on behalf of a third party.

YesNo
Section III
I believe the discrimination I experienced was based on (select all that apply):

RaceColorNational OriginDisability
Date of Alleged Discrimination (Month, Day, Year):

MonthDayYear
Date
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 persons who discriminated against you, if known, as well as names and contact information of any witnesses.
Section IV
Have you previously filed a Discrimination Complaint with this agency?

YesNo
If yes, please provide any reference information regarding your previous complaint.
Section V
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

YesNo
If yes, check all that apply:

Federal AgencyFederal CourtState CourtState AgencyLocal Agency
If you selected Federal Agency above, write name below (otherwise skip):
If you selected Federal Court above, write name below (otherwise skip):
If you selected State Court above, write name below (otherwise skip):
If you selected State Agency above, write name below (otherwise skip):
If you selected Local Agency above, write name below (otherwise skip):
Please use the following section to provide information about a contact person at the agency/court where the complaint was filed.
Name
Title
Agency
Address
Telephone
Section VI
Name of agency complaint is against
Name of person complaint is against
Title
Location
Telephone Number (if available)
You may attach any written materials or other information that you think is relevant to your complaint. Your signature and date are required below. Be sure to click the submit button to submit this complaint.

Cancelof
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Discrimination Complaint Form

Section I

Section II

Section III

Section IV

Section V

Section VI