Title II and Title VI Complaint Form

Title II and Title VI Complaint Form
I believe I have been discriminated against on the basis of...

Disability (Title II - ADA)Race, Color, or National Origin (Title VI - Civil Rights)
Title II - Americans with Disabilities Act

disABILITYsa is committed to ensuring that no person is excluded from participation in, or denied the benefits of its service, or otherwise subjected to discrimination, on the basis of disability– as protected by Title II of the Americans with Disabilities Act (ADA.)

If you require any assistance in completing this form, please contact the disABILITYsa Office by email at access@disabilitysa.org or by phone/text at (210) 704-7262.

The following information is necessary to assist us in processing your complaint.
Title VI - Civil Rights

disABILITYsa is committed to ensuring that no person is excluded from participation in or denied the benefits of or subject to discrimination in the receipt of its services or programs on the basis of race, color or national origin as protected by Title VI of the Civil Rights Acts of 1964, as amended.

If you require any assistance in completing this form, please contact the disABILITYsa Office by email at access@disabilitysa.org or by phone/text at (210) 704-7262.

The following information is necessary to assist us in processing your complaint.

Section One : Contact Information

Section 1 of 4
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Are you filing this complaint on your own behalf?

YesNo
Name of the person you are filing this complaint for:

First NameLast Name
Please explain why you are filing for a third party, and your relationship to the individual you are filing on behalf of:
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

Yes, I have the aggrieved party's permissionNo, I do not have the aggrieved party's permission

Section Two: Complaint

Section 2 of 4
I believe the discrimination I experienced was based on (check all that apply):

RaceNational OriginColorOther
Date of Alleged Discrimination:

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 person who discriminated against you (if known), as well as the names and contact information of any witnesses.
Type Your Response Here:
You may attach any materials/information you think is relevant to your complaint.

Cancelof

Section 3: External Agencies

Section 3 of 4
Have you filed a previous Title VI complaint against disABILITYsa?

YesNo
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 AgencyState CourtLocal Agency
Please list the agency/agencies where your complaint has been filed:
Please provide any information you have for a contact person at the external agency/court where the complaint was filed:
Name and Title

First NameLast NameTitle
Phone Number
Please enter a valid phone number.
Email
example@example.com

Submission

Section 4 of 4
I hereby attest that, to the best of my knowledge, the provided information is true.
Full Name (Print Signature)
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Should be Empty:

Section One : Contact Information